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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195850207
Report Date: 01/19/2022
Date Signed: 01/19/2022 12:43:57 PM

Document Has Been Signed on 01/19/2022 12:43 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:MARY'S CHATEAU IIFACILITY NUMBER:
195850207
ADMINISTRATOR:PETIKYAN, MARYFACILITY TYPE:
740
ADDRESS:15215 VALERIO STREETTELEPHONE:
(323) 333-8105
CITY:VAN NUYSSTATE: CAZIP CODE:
91405
CAPACITY: 6CENSUS: 0DATE:
01/19/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Mary Petrikyan, AdministratorTIME COMPLETED:
12:45 PM
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Licensing Program Analyst (LPA), Salia Walker conducted a pre-licensing inspection to this property at 10:30 a.m. on January 19, 2022, and met with applicant representative Mary Petikyan. The applicant has obtained fire clearance for a total capacity of five (5) non-ambulatory residents, and one (1) bedridden resident for a total capacity of six (6) clients. Fire clearance indicates shared room ‘Bedroom #4 or for 1 bedridden patient.’

The LPA inspected the facility for Fire Safety, Personal Accommodations and Services, and Food Service. At 11:38 a.m., all hard- wired smoke alarms and carbon monoxide detectors were tested and function properly. The LPA observed two fire extinguishers to be fully charged with a purchase date of 08/18/21. There are two (2) single occupancy bedrooms, and two (2) double occupancy bedrooms for resident use. One (1) out of three (3) resident bedrooms have a private bathroom. There are no staff bedrooms in the facility. 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 (2) common bathrooms for resident use. All common and private bathrooms contain appropriate non-skid mats and grab bars. Bathrooms have sufficient paper products, and hand washing signs. Night-lights were present in the main hallway. Between 10:43 a.m. and 10:53 a.m., hot water temperatures measured between 112.3 and 113.7 degrees Fahrenheit in the common and private bathroom(s).

The LPA toured the kitchen area at 10:54 a.m. The facility has a sufficient (7) day supply of non-perishable food, and will purchase perishable food upon admission of clients. 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. Hot water measured at 116.2 degrees Fahrenheit at 10:58 a.m.

Continue LIC 809C..

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Salia Walker
LICENSING EVALUATOR SIGNATURE: DATE: 01/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/19/2022
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: MARY'S CHATEAU II
FACILITY NUMBER: 195850207
VISIT DATE: 01/19/2022
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The living areas and dining areas are clean and properly furnished. All window screens and coverings are in good repair. The facility has enough seating to accommodate all residents. A working telephone is present. There are activity supplies stored cabinet located in the facility kitchen. Medications will be stored and locked in a cabinet located in the common space next to the facility kitchen. 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 file cabinet. Cleaning and disinfectants are stored and inaccessible away in utility room. Laundry area is located in the facility’s utility room. Laundry detergents and personal hygiene items are stored in the utility room. There is an adequate supply of emergency water, along with emergency nonperishable food items kept in the storage room. 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 has 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 currently does not have an adequate 30-day supply of Personal Protection Equipment (PPE), and has placed a request order with the LPA. 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. At 11:05 a.m., the LPA observed the backyard, which has a covered outdoor area for resident use. There are two (2) self-latching gates on the side of the house designated for an emergency exit. Physical plant was not consistent with the submitted facility sketch/floor plan as it reflected Bedroom #3 to have a private bathroom. The applicant submitted an updated facility sketch/floor plan accurately reflecting a closet versus a private bathroom.
During today’s visit, the LPA reviewed the facility’s program plan, personnel policies, abuse reporting procedures, in-service training protocol, and medication procedures. The facility’s Mitigation Plan Report was provided during the pre-licensing inspection.

Comp III conducted.
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 under the new facility license number, until you have been notified that your license has been approved by the CAB Analyst. Failure to comply could affect approval of your license.
The physical plant of this facility location is in compliance with Title 22 regulations at this time. Exit interview conducted. A copy of the report was provided.

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Salia Walker
LICENSING EVALUATOR SIGNATURE:

DATE: 01/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/19/2022
LIC809 (FAS) - (06/04)
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