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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195850280
Report Date: 11/17/2022
Date Signed: 11/18/2022 12:13:44 PM

Document Has Been Signed on 11/18/2022 12:13 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:FRIENDSHIP VILLAGE RCFFACILITY NUMBER:
195850280
ADMINISTRATOR:MKRTCHIAN, VAHEFACILITY TYPE:
740
ADDRESS:12950 HAYNES STTELEPHONE:
(818) 414-0005
CITY:NORTH HOLLYWOODSTATE: CAZIP CODE:
91606
CAPACITY: 6CENSUS: 0DATE:
11/17/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Vahe MkrtchianTIME COMPLETED:
12:30 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
The pre-licensing visit was conducted by Licensing Program Analyst (LPA), Sandra Urena. The LPA arrived
at the facility at 10:00 a.m., and met with applicant Vahe Mkrtchian. This is a new facility application for six residents. Fire Clearance was approved on 09/30/2022 for one bedridden resident, and resident is allowed to reside in either bedroom # 1,2,3, or 4.

At 10:25 a.m., the LPA, and the applicant toured the physical plant areas inside and outside to ensure there
are no health and safety hazards, and facility is in compliance with Title 22 Regulations.

KITCHEN: A seven day supply of non-perishable food was available. The supply of dishes is adequate.
Appliances in the kitchen were clean and all appeared functional. Kitchen, and house cleaning supplies will be stored in locked cabinet in the hallway. Hot water temperature was recorded at 118.2 Fahrenheit degrees
Trash cans have a tight-fitting lid. There were no pesticides or toxins stored near food, or preparation area.

BEDROOMS: Facility has five (5) bedrooms. Four (4) bedrooms are for resident use, and one (1) bedroom for staff use. Bedrooms #2 and #3 are for double occupancy. Bedrooms #1, and #4 are private bedrooms. All bedrooms are approved for one (1) bedridden resident. Facility sketch describes bedroom #3 as the bedroom designated for the bedridden resident. Lighting in the rooms appeared adequate. All bedrooms had adequate closet and drawer space for clothing and personal belongings.

BATHROOMS: Two bathrooms are fully stocked with paper towels, and liquid hand soap. The showers have non-skid surface mats. Hot water temperature was recorded at 118.2 Fahrenheit degrees. Hand washing signs were visible and posted. Bathroom #1 and #2 are designated for residents, and staff use. They are fully equipped with handlebars and nonskid surfaces.
Continues LIC 809 C...
SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Sandra Urena
LICENSING EVALUATOR SIGNATURE: DATE: 11/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/17/2022
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: FRIENDSHIP VILLAGE RCF
FACILITY NUMBER: 195850280
VISIT DATE: 11/17/2022
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
COMMON AREAS: The common areas were appropriately furnished, and the lighting was adequate.

Residents and staff records will be stored in a filing cabinet in a locked closet located next to bedroom#1. Medications will be stored in a locked closet located next to bedroom #1. The first aid supplies were complete, including a thermometer and a current version of a first aid manual, which will be locked in the closet next to bedroom #1.

The facility’s smoke/carbon monoxide alarm systems are hard wired. The alarm systems are installed in the hallway, living room area, and bedrooms. All rooms were tested, and all smoke/carbon monoxide alarm systems were in operating condition. A fire extinguisher is properly charged, and is located mounted on the wall in the kitchen area, close to the back exit door.

The supply of extra bed, and bath linens is adequate, and is located in a closet in the hallway. There is a functioning land line telephone on the premises. Infection control, and other posters are posted throughout the facility, and hallways.

The exterior passageways were clean, and clear of any obstructions. The front patio is furnished with outdoor furniture for residents’ use, and shade is available. The building has a central entrance for residents, and visitors. Fire emergency gates are clear of obstructions.

The applicant completed Component III Orientation.

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 was conducted, and reviewed with applicant Vahe Mkrtchian. A copy of the report was issued.

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

DATE: 11/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2