<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195850166
Report Date: 06/04/2021
Date Signed: 06/04/2021 11:51:40 AM

Document Has Been Signed on 06/04/2021 11:51 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:AAA QUALITY RESIDENTIAL CARE FACILITYFACILITY NUMBER:
195850166
ADMINISTRATOR:KIRAKOSYAN, ELENFACILITY TYPE:
740
ADDRESS:7843 STANSBURY AVE.TELEPHONE:
(323) 485-4851
CITY:PANORAMA CITYSTATE: CAZIP CODE:
91402
CAPACITY: 6CENSUS: 0DATE:
06/04/2021
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Elen KirakosyanTIME COMPLETED:
12:00 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 Analysts (LPAs), Emily Peraldi, Brian Balisi, and Salia Walker conducted a pre-licensing visit to this property at 10:06am on 06/04/2021 and met with applicant representatives Elen Kirakosyan, Cristine Gasparyan, Ovsanna Khayalyan. The applicant has obtained fire clearance for a total capacity of five (5) non-ambulatory residents, and one (1) bedridden resident (in bedroom #1) for a total capacity of six (6) clients.
LPAs inspected facility for Fire Safety, Personal Accommodations and Services, and Food Service. At 10:29am all hardwired smoke alarms and carbon monoxide detectors were tested and function properly. LPAs observed one fire extinguisher to be fully charged. Fire extinguisher purchased on 04/30/2021.
There are three (3) double occupancy bedrooms for resident use. There is no-live in staff bedroom. Facility must have 24-hour wake staff. Each bedroom is equipped with clean mattresses, pillows and bedding. There is sufficient supply of linens, including blankets, bath towels and wash cloths. Bedrooms have sufficient lighting. The facility has two bathrooms, one for resident use and one for staff use. Resident bathroom contained appropriate non-skid mats and grab bars. Bathroom has sufficient paper products. Night-lights were present in the main hallway. Hot water measured at 105.6 Fahrenheit at 10:16am.
LPAs toured the kitchen area at 10:12am. The facility has (7) day supply of non-perishable food. Appliances and all equipment appear to be clean and in good repair. Kitchen knives are stored in a locked cabinet. The kitchen has a sufficient supply of plates, cups, cook ware and utensils. Range will be inaccessible. Hot water measured at 108.2 Fahrenheit at 10:35am.
The living areas and dining areas are clean and properly furnished. All window screens and coverings are in good repair. A working telephone is present. There are activity supplies.
Medications will be stored and locked in a kitchen cabinet. First aid kit was observed to have bandages, thermometer, scissors, tweezers and a current first aid manual. Facility records will be stored and locked in office area. Cleaning and disinfectants are stored and inaccessible away in the locked staff bathroom.

Continuation on LIC809-C.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Emily Peraldi
LICENSING EVALUATOR SIGNATURE: DATE: 06/04/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/04/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
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: AAA QUALITY RESIDENTIAL CARE FACILITY
FACILITY NUMBER: 195850166
VISIT DATE: 06/04/2021
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
26
27
28
29
30
31
32
Laundry area is located in the staff bathroom. Laundry detergents and personal hygiene items are stored in the locked staff bathroom. There is an adequate supply of emergency water located outside in a locked shed. There will be no firearms/ammunition stored on the property.
The facility has required postings, including emergency exit plan, Licensing Complaint Poster, Resident Personal Rights, Theft and Loss Policy, and Resident Council Rights.

Facility will have one central entry point designated for universal screening. Alcohol-based hand sanitizer available upon entry. Signs are posted throughout the facility to promote hand washing, and cough/sneeze etiquette. Facility will have adequate 30-day supply of Personal Protection Equipment (PPE).

The exterior passageways were clean and clear of any obstructions. There are no bodies of water on the premises at the time of the visit. The LPAs observed the backyard, which has a covered outdoor area for resident use. Self-latching gate located at the side of the facility. Physical plant is consistent with the submitted facility sketch/floor plan.

During today’s visit, LPAs reviewed facility’s program plan, personnel policies, abuse reporting procedures, in-service training protocol, and medication procedures.
The physical plant of this facility location is in compliance with Title 22 regulations at this time.

Component III Orientation was conducted in conjunction with the visit at 10:24am.

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.

Exit interview conducted 11:40am. A copy of the report was provided via email.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Emily Peraldi
LICENSING EVALUATOR SIGNATURE:

DATE: 06/04/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/04/2021
LIC809 (FAS) - (06/04)
Page: 2 of 2