195850295-12-2-2022-29-AS-SURA-CLQM43-20221202081603

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 195850295
Report Date: 12/01/2022
Date Signed: 12/02/2022 08:18:30 AM

Document Has Been Signed on 12/02/2022 08:18 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:	CALA HOMES		FACILITY NUMBER:	195850295
ADMINISTRATOR:	GHAZARYAN, NARINE		FACILITY TYPE:	740
ADDRESS:	7331 LEMONA AVENUE		TELEPHONE:	(818) 636-1064
CITY:	VAN NUYS	STATE: CA	ZIP CODE:	91405
CAPACITY: 6		CENSUS: 0	DATE:	12/01/2022
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Julietta Mirzoyan		TIME COMPLETED:	01:30 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 10:30 a.m., and met with applicant Julietta Mirzoyan. This is a new facility application for a total of six residents, five non-ambulatory, and one bedridden. Fire Clearance was approved on 08/12/2022 for one bedridden resident, and resident is allowed to reside in bedroom # 3. At 10:35 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. Hot water temperature was recorded at 124.5 Fahrenheit degrees Trash cans have a tight-fitting lid. There were no pesticides or toxins stored near food, or preparation area. BEDROOMS: Facility has four (4) bedrooms, and the four (4) bedrooms are for resident use. There is no bedroom available for staff use. Bedrooms #1 and #2 and #4 are for double occupancy. Bedroom #3 is designated as a private bedroom. Bedroom #3 is 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: The facility has two bathrooms; one for resident use, and one for staff use. Bathroom # 1 is for residents’ use and is fully stocked with paper towels, and liquid hand soap. The shower has non-skid surface mat. Hot water temperature was recorded at 122.8. Fahrenheit degrees. Hand washing signs were visible and posted. Bathroom #2 is designated for staff use. Bathroom #2 needs to be stocked with paper towels. 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: 12/01/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2022

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: CALA HOMES	FACILITY NUMBER: 195850295
	VISIT DATE: 12/01/2022

NARRATIVE

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COMMON AREAS: The common areas were appropriately furnished, and the lighting was adequate. There
is a television in the living room area. Board games, books and magazines are available in the living room area. The first aid supplies were complete, including a thermometer, and a current version of a first aid manual. The kit is located in a cabinet in the common area of the living room.

Residents, and staff records will be stored and locked in a filing cabinet in the kitchen. Medications will be stored in a locked cabinet found in the hallway, between bedroom #1 and the bathroom.

The facility’s smoke/carbon monoxide alarm systems are hard wired. 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.

The laundry room is located in the kitchen area. The supply of linens is insufficient to permit changing weekly or more often as needed to ensure use of linens at all times. Applicant was advised to obtain additional linens.

There is a functioning land line telephone found in the living room area. Infection control, and other
posters are posted throughout the facility and hallways.

The exterior passageways were clean, and clear of any obstructions. The 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.

Continues on LIC809C...

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Sandra Urena
LICENSING EVALUATOR SIGNATURE:	DATE: 12/01/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2022

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: CALA HOMES	FACILITY NUMBER: 195850295
	VISIT DATE: 12/01/2022

NARRATIVE

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Pre-Licensing is incomplete with deficiencies to be resolved. During the inspection, the LPA, and Applicant
observed the following corrections needed prior to being licensed:

1. Lower water temperature in kitchen and bathrooms #1 and #2 to be between 105 to 120 degrees Fahrenheit.
2. Add signal system to bedroom #3 for bedridden resident.
3. Contact Centralized Application Bureau(CAB) and Fire Department for changes in the location(bedroom) of the bedridden resident.
3. Add paper towels to bathroom #2.
4. Obtain a sufficient supply of linens to permit changing weekly or more often as needed to ensure use of linens at all times.
5. Create a passageway for residents and non-ambulatory residents to access the outdoor area.

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 Julietta Mirzoyan. A copy of the report was
issued.

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Sandra Urena
LICENSING EVALUATOR SIGNATURE:	DATE: 12/01/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2022

LIC809 (FAS) - (06/04)

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