565850434-7-29-2024-29-AS-BBAI-D7MSPV-20240729140346

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565850434
Report Date: 07/29/2024
Date Signed: 07/29/2024 02:04:25 PM

Document Has Been Signed on 07/29/2024 02:04 PM - 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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	SENIORS DIGNITY CARE		FACILITY NUMBER:	565850434
ADMINISTRATOR:	MANUKYAN, ANAHIT		FACILITY TYPE:	740
ADDRESS:	6306 MARSHA AVE		TELEPHONE:	(805) 624-7109
CITY:	SIMI VALLEY	STATE: CA	ZIP CODE:	93063
CAPACITY:	6	CENSUS: 5	DATE:	07/29/2024
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Anahit Manukyan		TIME COMPLETED:	02:15 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Brian Balisi conducted a pre-licensing visit to the above noted facility. The LPA met with applicant Anahit Manukyan. This is a Change of Ownership (CHOW). The facility is currently licensed under Seniors Serenity #565850208 A dementia program was included in the plan of operation. A Hospice Waiver has been requested. The current capacity is for six (6) clients. The fire clearance was granted for five (5) non-ambulatory clients and one (1) bedridden client. There are currently five (5) residents in care. The facility is one story. At approx. 10:00am, a physical plant tour was conducted inside and out. The facility has four (4) private resident bedrooms. Resident rooms #1, #2 and #3 have a direct exit to the outside. Bedroom #2 is approved for one (1) bed-ridden resident. There are no fire sprinklers in the facility. All resident bedrooms were observed to be equipped with fire door. All resident rooms are set up with beds, nightstands, lamps, chests of drawers, chairs and closet space. The beds are furnished with box springs, comfortable mattress and clean linen; which includes, a mattress pad, top and bottom linens, pillowcases, blanket (if needed) and a bedspread. Lighting in the rooms appeared adequate. In addition, no bedroom was used as a passageway to another room, bath or toilet. There is a staff room at the facility located on left side of hallway. LPA observed room to be inaccessible to residents in care. For NOC , there will be awake night staff only. All rooms were free of odors. All window screens were clean and maintained in good repair. There are three (3) bathrooms total. The resident bathroom(s) have a shower with non-skid materials. The toilet and shower have grab bars. The hot water temperature was tested in the bathrooms and the kitchen and was found to be within the range of 105F and 120F.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian Balisi	TELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:	DATE: 07/29/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2024

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: SENIORS DIGNITY CARE	FACILITY NUMBER: 565850434
	VISIT DATE: 07/29/2024

NARRATIVE

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Resident and staff records are to be stored inaccessible in a hallway closet. Medications are centrally stored inaccessible in a locked cabinet in the kitchen. The first aid supplies were complete , including a thermometer and a current version of a first aid manual. First aid was observed stored in cabinet in living room.

Kitchen knives are stored in accessible in a drawer to the right of the sink. Stove burners are rendered inaccessible to the residents by placing a safety lock on them when not in use. The supply of dishes, utensils, pots, pans and drinkware is adequate. The freezer was maintained at zero degrees Fahrenheit (0*F) and the refrigerator was maintained at 40*F. The supply of nonperishable food is adequate. There are no pesticides (poisons) or toxins stored in any food storage area or preparation area with utensils. Appliances in the kitchen were clean and all appeared functional at the time of the visit. Trash cans had tight fitting lids. No flies or other vermin were observed.

The common areas were appropriately furnished, and the lighting was adequate. There is a television and other entertainment equipment, games and/or activity supplies in the living room. There was sufficient space to accommodate both indoor and outdoor activities. Night lights were maintained in hallways and passageways to non private bathrooms. There is no fireplace in the living room.

The facility has emergency exit signs . The facility has a furnace, which is able to heat rooms that residents occupy to a minimum of 68 degrees Fahrenheit; and, they have central air conditioning and are able to cool rooms to a comfortable range, not to exceed 85 degrees Fahrenheit.
The facility smoke alarm system is battery operated. The smoke detector and carbon monoxide detectors were tested and functioned properly during the time of visit. Fire extinguishers were observed fully charged and last serviced in June 15, 2024.

The laundry room is located in the rear of the facility. Cleaning supplies and toxins were observed stored here and the room will be inaccessible to residents in care. There is an attached garage that is only accessible from the exterior of the home. LPA observed extra furniture and other supplies for facility use along with a supply of emergency food.

Continued from 809-C

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian Balisi	TELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:	DATE: 07/29/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2024

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: SENIORS DIGNITY CARE	FACILITY NUMBER: 565850434
	VISIT DATE: 07/29/2024

NARRATIVE

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Continued from 809-C

There is cabinet located in the main hallway that stored an adequate supply of extra bed and bath linens. Cabinets are to be locked and inaccessible to residents in care. There is a functioning telephone on the premises. The emergency exiting plans/sketch are posted throughout. The emergency telephone numbers and other required postings are posted in the kitchen.

The exterior passageways were clean and clear of any obstructions. There is a covered patio area in the rear of the home. LPA observed appropriate furniture for outdoor use. The outside area was observed to be large enough to conduct outdoor activities. There is no body of water observed at this time.

Component III and interviews were conducted in conjunction with the visit.

No corrections required on a pre-licensing visit at this time. Exit interview conducted. Report issued and provided to Licensee.

This report will be sent to the Centralized Application Bureau (CAB). You will be notified by the CAB Analyst when your license has been approved. You are not allowed to begin operating until you have been notified that your license has been approved by the CAB Analyst. Failure to comply could affect approval of your license.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian Balisi	TELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:	DATE: 07/29/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2024

LIC809 (FAS) - (06/04)

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