195850350-4-25-2023-29-AS-SURA-CR8KF9-20230425075132

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 195850350
Report Date: 04/24/2023
Date Signed: 04/25/2023 07:51:49 AM

Document Has Been Signed on 04/25/2023 07:51 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:	LA SENIOR HOME		FACILITY NUMBER:	195850350
ADMINISTRATOR:	SPRY, NAIRA		FACILITY TYPE:	740
ADDRESS:	7825 SIMPSON AVENUE		TELEPHONE:	(818) 299-7501
CITY:	NORTH HOLLYWOOD	STATE: CA	ZIP CODE:	91605
CAPACITY: 5		CENSUS: 0	DATE:	04/24/2023
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Administrator Naira Spry, and applicant Tigran Gevorgyan		TIME COMPLETED:	02:30 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	Licensing Program Analyst (LPA) Sandra Urena conducted a Pre-licensing visit at 9:45 a.m., and met with the Administrator Naira Spry, and applicant Tigran Gevorgyan. This is a new application for Residential Care Facility for the Elderly (RCFE) with a capacity for five (5) residents. Four(4) non-ambulatory residents, and one(1) bedridden resident. The facility was cleared by the Los Angeles Fire Department to have the bedridden resident in bedroom three(3). The facility is a one story dwelling, with one detached storage unit, and a detached second dwelling in the back, which is not leased to the applicant at the time of the pre-licensing visit. Per applicant there is no one living in the dwelling, and does not have keys for dwelling. . Consequently, the LPA did not have access to inspect the detached dwelling, and detached storage unit. At 10:15 a.m., the LPA, Administrator and Licensee (applicant) toured the physical plant areas inside and outside to ensure there are no health and safety hazards and that the facility is in compliance with Title 22 Regulations. KITCHEN: Kitchen knives are stored locked and inaccessible in a kitchen cabinet. 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 are stored in a locked cabinet under the sink. Hot water temperature was recorded at 108.7 degrees Fahrenheit. Trash cans have a tight-fitting lid. There were no pesticides or toxins stored near food, or preparation area. BEDROOMS: There are three (3) bedrooms. Bedroom one (1) is for double occupancy, bedroom two (2) is single occupancy, and bedroom three (3) is a shared room, and designated for the bedridden resident. All bedrooms were supplied with all required bedding and linens. There is sufficient lighting as well as closet, and drawer space available. BATHROOMS: There is one (1) full bathroom. Bathroom was equipped with toilet and shower grab bars. There are sufficient supplies of towels, paper goods and personal hygiene supplies. Hot water was recorded at 108.2 degrees Fahrenheit .

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Sandra Urena
LICENSING EVALUATOR SIGNATURE:	DATE: 04/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2023

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: LA SENIOR HOME	FACILITY NUMBER: 195850350
	VISIT DATE: 04/24/2023

NARRATIVE

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COMMON AREAS: There is a living room/dining room space equipped with a television. There is a dedicated area for the posting of required documents in the dining area. 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 properly charged is located mounted on the wall of the kitchen area. Medication will be stored in a locked kitchen cabinet. Residents’, and staff files will be stored and locked in an office space area. There is a functioning land line telephone on the premises.

OUTDOOR AREA: 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 gate is clear of obstructions.
LAUNDRY ROOM: A laundry area room is attached to the dwelling is equipped with a washer and dryer. Detergents and cleaning supplies will be stored in locked cabinet.

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. Sliding Door for bedroom three (3) needs to be leveled, and be positioned at the level where wheelchairs and walkers may pass through safely.
2. At the time of the Pre-licensing visit the applicant has decided to fence the facility to prevent direct access to any person who is not associated, and background cleared to the facility/Get keys from landlord to have access for LPA to inspect the dwelling.
3. Add bed to bedroom one (1).
At 12:30 p.m., 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 Administrator Naira Spry, and applicant Tigran Gevorgyan . A copy of the report was issued.

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Sandra Urena
LICENSING EVALUATOR SIGNATURE:	DATE: 04/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2023

LIC809 (FAS) - (06/04)

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