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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195850146
Report Date: 05/18/2021
Date Signed: 05/18/2021 10:27:53 AM

Document Has Been Signed on 05/18/2021 10:27 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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:MY HOME OF AGINGFACILITY NUMBER:
195850146
ADMINISTRATOR:KYKHOSROWPOUR, VISHTASBFACILITY TYPE:
740
ADDRESS:23817 BESSEMER STREETTELEPHONE:
(818) 640-1572
CITY:WOODLAND HILLSSTATE: CAZIP CODE:
91367
CAPACITY: 6CENSUS: 0DATE:
05/18/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Vishtasb KykhosrowpourTIME COMPLETED:
10:45 AM
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Licensing Program Analyst (LPA) Aja Richardson conducted a Prelicensing visit at 9 am and met with the Administrator and applicant Vishtasb Kykhosrowpour. This visit is for an initial application for Residential Care Facility for the Elderly (RCFE) with a capacity of 6. Approved for 6 bedridden residents.

At 9 am, a tour of the physical plant was conducted. During the visit LPA observed the following:

KITCHEN: The facility is equipped with a spacious kitchen that is supplied with adequate dining and cook ware. Appliances and fixtures are clean and functional. The kitchen trash can was equipped with a lid.

BEDROOMS: There are (6) bedrooms for residents in care. All six rooms are private rooms and cleared for bedridden residents. There are no staff rooms. All bedrooms were supplied with all required bedding and linens. There is sufficient lighting as well as closet and drawer space available.

BATHROOMS: There are (4) full bathrooms. Bathrooms are equipped with toilet and shower grab bars. There is sufficient supplies of towels, paper goods and personal hygiene supplies. Hot water delivered between 107.1 and 109 degrees F.
SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Aja Richardson
LICENSING EVALUATOR SIGNATURE: DATE: 05/18/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/18/2021
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: MY HOME OF AGING
FACILITY NUMBER: 195850146
VISIT DATE: 05/18/2021
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COMMON AREAS: These include a living space equipped with a television. There is a dedicated area for the posting of required documents in the dining area. Smoke detectors checked and is connected to carbon monoxide. Medication are stored in hallway closet and resident and staff files are stored locked kitchen.

LAUNDRY ROOM: There is a laundry area equipped with washer and dryer in the attached garage. Detergents and cleaning supplies will be stored in locked cabinet in garage.

SURROUNDING GROUNDS: The property is equipped with fencing and gates . There is furniture appropriate for outdoor use including a covered patio providing shade. There is a pool surrounded by a locked gate.


At this time facility has passed prelicensing inspection,

Exit Interview Conducted. Report emailed to Administrator.
SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Aja Richardson
LICENSING EVALUATOR SIGNATURE:

DATE: 05/18/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2021
LIC809 (FAS) - (06/04)
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