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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195850206
Report Date: 08/04/2022
Date Signed: 08/04/2022 01:32:03 PM

Document Has Been Signed on 08/04/2022 01:32 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:
08/04/2022
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Anna Hakobyan - LicenseeTIME COMPLETED:
10:30 AM
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Licensing Program Analyst (LPA) Brian Balisi along with North Los Angeles County Regional Center Community Services Specialists Fred Rockwood and Trinidad Hicks conducted an unannounced Post Licensing Visit. At approx 8:30am, LPA and Regional Center Specialists were met by Licensee Anna Hakobyan and LPA explained the reason for the visit. There were no residents at the time of the visit.

At approximately 8:35am LPA conducted physical plant along with Administrator Regional Center. LPA inspected facility for Fire Safety, Personal Accommodations and Services, and Food Service. Smoke detectors and Carbon Monoxide detectors were tested and functioned 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 relatively clean at this time and the appliances and fixtures functional during the time of visit. LPA 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: 08/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/04/2022
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: 08/04/2022
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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 105 - 120 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 gated swimming pool located in the backyard. Garage was accessible from the exterior of the building. Licensee opened garage and LPA observed building material, non-perishable foods, extra medical supplies and equipment.

At approx 8:50am, LPA and Regional Center Specialists observed a large building under construction. Building was not present during Pre-Licensing visit on 3-8-2022. Licensee stated they are building a storage unit. Licensee provided LPA with documentation of approved plans, permit and survey.

Regional Center Specialists advised Licensee to remove the ramp on the exit way of room #5 as it is a potential hazard for future residents who may be able to access the gated pool by using the hand rails to climb over the fence.

Licensee was also advised to put up gate between garage and neighboring fence once construction debris are cleared in between this area. Licensee will update Regional Center and LPA once tasks are complete.

No immediate health and safety concerns were observed during the visit. Exit interview conducted, report issued and sent via email.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:

DATE: 08/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

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