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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195850207
Report Date: 11/29/2022
Date Signed: 11/30/2022 08:29:39 AM

Document Has Been Signed on 11/30/2022 08:29 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: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: 5DATE:
11/29/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:35 PM
MET WITH:Mary PetikyanTIME COMPLETED:
03:45 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 Analyst (LPA) Sandra Urena arrived at the facility unannounced to conduct a required
annual visit at 1:35 p.m. This annual inspection had an emphasis on infection control practices and procedures. The LPA initially met with staff, whom contacted the Administrator. The LPA spoke with Administrator Mary Petikyan over the phone and informed them of the reason for the visit. The Administrator Mary Petikyan explained that they would arrive at the facility within 40 minutes.

The LPA, and the administrator toured the physical plant areas inside and outside from 2:05 p.m. to 2:46 p.m. to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations.

KITCHEN: The facility has a sufficient (7) day supply of non-perishable food, and perishable. 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.


BEDROOMS: There are four (4) bedrooms. One (1) out of four (4) residents' bedrooms have a private bathroom. 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.

BATHROOMS: 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.

Continue LIC 809C...

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Sandra Urena
LICENSING EVALUATOR SIGNATURE: DATE: 11/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/29/2022
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: MARY'S CHATEAU II
FACILITY NUMBER: 195850207
VISIT DATE: 11/29/2022
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
OUTDOOR AREA: The backyard has patio furniture, and shade for residents’ use. There is one (1) self-latching gate on the side of the house designated for an emergency exit.

INFECTION CONTROL: There is a central entry point for screening and temperature checks. Signs were posted that promoted good hand hygiene, physical distancing, and cough/sneeze etiquette. The facility’s cleaning protocol is sufficient. The facility can designate a room to isolate persons if there is a confirmed case of COVID-19. Staff are up to date regarding guidelines around visitation and vaccine requirements. The policies and procedures pertaining to infection control were adequate.

No deficiencies cited. Exit interview was conducted. The report was reviewed with the administrator, and signatures were obtained. A copy of the report was provided via email.

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Sandra Urena
LICENSING EVALUATOR SIGNATURE:

DATE: 11/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/29/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2