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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881581
Report Date: 09/04/2024
Date Signed: 09/04/2024 08:46:36 AM


Document Has Been Signed on 09/04/2024 08:46 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 744 P STREET, MS 9-14-8201
SACRAMENTO, CA 95814



FACILITY NAME:LUNA SENIOR LIVINGFACILITY NUMBER:
331881581
ADMINISTRATOR:HOVSEPIAN, SAHAKFACILITY TYPE:
740
ADDRESS:1361 E LUNA WAYTELEPHONE:
(818) 641-9222
CITY:PALM SPRINGSSTATE: CAZIP CODE:
92262
CAPACITY:6CENSUS: 3DATE:
09/04/2024
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
08:25 AM
MET WITH:Sahak Hovespian, Applicant/AdministratorTIME COMPLETED:
08:30 AM
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Component II completion: Successful

Facility Type: Residential Care Facility for the Elderly (RCFE)
Application Type: Change in Ownership (CHOW)
Capacity: 6
Census (if any clients in care): 3
COMP II Participants: Sahak Hovespian, Applicant/Administrator
Interview Method: Waived

On July 26, 2024 at 2PM, Applicant/Administrator participated in COMP II for the below pending facilities: Luna Senior Services Facility #331881617. Identification of the Applicant/administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, Applicant/Administrator confirmed that they have read and understand community care facility licensing laws included in the Health and Safety Codes and the California Code of Regulations Title 22.

During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas:
1. Facility Operation: License type, client/resident populations, and program
2. Admission Policies
3. Staffing Requirements & Training
4. Restrictive/Prohibited Health Conditions
5. General Provisions
6. Emergency Preparedness
7. Complaints & Reporting
8. Pre-licensing Readiness
SUPERVISOR'S NAME: Darla NeeleyTELEPHONE: (916) 651-7817
LICENSING EVALUATOR NAME: Celia PhomphachanhTELEPHONE: 916-657-2469
LICENSING EVALUATOR SIGNATURE:
DATE: 09/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/04/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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