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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195850206
Report Date: 03/08/2022
Date Signed: 03/08/2022 12:25:32 PM

Document Has Been Signed on 03/08/2022 12:25 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:A'VILLAFACILITY NUMBER:
195850206
ADMINISTRATOR:HAKOBYAN, ANNAFACILITY TYPE:
740
ADDRESS:6532 GLORIA AVE.TELEPHONE:
(310) 435-1445
CITY:LAKE BALBOASTATE: CAZIP CODE:
91406
CAPACITY: 6CENSUS: 0DATE:
03/08/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Anna Hakobyan TIME COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA) Brian Balisi conducted a Pre-licensing visit to the above facility. LPA met with Administrator Anna Hakobyan and explained the reason for the visit. This home is licensed to serve (6) non-ambulatory residents.

At approximately 10:15am LPA conducted physical plant along with Administrator. LPA inspected facility for Fire Safety, Personal Accommodations and Services, and Food Service. Smoke detectors and Carbon Monoxide detectors appeared to function properly during time of visit.

Facility is a single-story residence and consists of a total of five (5) bedrooms and two (2) bathrooms designated for clients use. (1) bedroom is designated for staff use at this time. Fire extinguishers were observed to be fully charged and purchased in December 2021. During physical plant tour LPA observed the required postings throughout the facility.

Kitchen: The kitchen appeared to be clean at this time and the appliances and fixtures functional during the time of visit. LPs observed a sufficient amount of perishable and non-perishable food at the facility; properly stored. Sharp objects were observed stored in locked drawer to the right of the sink. No Cleaning supplies and toxins were observed in this area at this time To the right of the kitchen was the laundry area. Cleaning supplies were observed to be stored and locked in cabinets above the washer and dryer and in a cabinet under the sink located in this area as well.

Bedrooms: The resident bedrooms were properly furnished with a bed, night stand, and sufficient lighting for each resident. The bedrooms had appropriate and adequate bedding and linens such as sheets, pillowcases, mattress pads, and blankets. LPA observed a sufficient supply of linen and personal hygiene supplies in the hallway closet right outside of bedroom #1.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE: DATE: 03/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/08/2022
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: A'VILLA
FACILITY NUMBER: 195850206
VISIT DATE: 03/08/2022
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Continued from 809

Bathrooms: LPA observed all bathrooms were clean, properly supplied and had functional fixtures. The hot water was measured in each bathroom between between 107 - 112 degrees Fahrenheit at this time.

Common Areas: These included the living room, dining area and office area. The common areas were checked for cleanliness and furniture was checked for functionality during time of visit. Dining room furniture appeared to be relatively clean and functional at this time. Medications, first aid and facility files are to be stored in locked cabinet outside of bedroom #1. LPA observed a locked cabinet that stored a sufficient amount of PPE, linen and extra medical supplies outside of bedroom #2

Outdoor Area: There was a shaded area with sufficient room for activities. LPA observed sufficient furniture designated for outdoor use. LPA also observed a pet tortoise. There is a swimming pool in located in the backyard. LPA observed it to be fenced and the gate locked. Garage was accessible from the exterior. LPA observed a sufficient amount of PPE at this time. The garage mainly stored linen, some furniture pieces, and medical supplies.

Comp III was completed in conjunction with the visit.

Pursuant to Title 22, Division 6, facility observed to be compliant with regulation. No corrections needed at this time. A copy of this report will be forwarded to the application specialist with LPA's recommendation for licensure. An exit interview was conducted with Administrator, and a hard copy was provided via email.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:

DATE: 03/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2022
LIC809 (FAS) - (06/04)
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