195850361-8-22-2023-29-AS-BBAI-CUXRAJ-20230822125112

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 195850361
Report Date: 08/22/2023
Date Signed: 08/22/2023 12:51:52 PM

Document Has Been Signed on 08/22/2023 12:51 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 III		FACILITY NUMBER:	195850361
ADMINISTRATOR:	PETIKYAN, MARY		FACILITY TYPE:	741
ADDRESS:	14835 WEDDINGTON ST		TELEPHONE:	(323) 333-8105
CITY:	SHERMAN OAKS	STATE: CA	ZIP CODE:	91411
CAPACITY: 6		CENSUS: 0	DATE:	08/22/2023
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Mary Petikyan		TIME COMPLETED:	01:00 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) Brian Balisi conducted a pre-licensing visit to the above noted facility. The LPA met with applicant Mary Petikyan. This is a new facility. A dementia program was included in the plan of operation. A Hospice Waiver has been requested. The facility is one story. At approx. 10am, a physical plant tour was conducted inside and out. An approved fire clearance was received, clearing them for (5) non-ambulatory residents and (1) bed ridden resident, with bed ridden resident to be residing in room #6; The facility has (6) private resident bedrooms. Resident rooms # 2 and #6 have direct exits to the outside. There are fire sprinklers in the facility. All resident rooms are set up with beds, nightstands, lamps, chests of drawers, chairs and closet space. The beds are furnished with box springs, comfortable mattress and clean linen; which includes, a mattress pad, top and bottom linens, pillowcases, blanket (if needed) and a bedspread. Lighting in the rooms appeared adequate. The bedrooms were large enough to allow for easy passage between the beds and furniture with a wheelchair or walker. In addition, no bedroom was used as a passageway to another room, bath or toilet. There is one (1) staff room that is to be used as storage at this time. For NOC , there will be awake night staff only. All rooms were free of odors. All window screens were clean and maintained in good repair. There are three (3) bathrooms in the hallway and (1) one bathroom in Resident room #2. The resident bathroom(s) have a shower with non-skid materials. The toilet and shower have grab bars. The hot water temperature was tested in the bathrooms and the kitchen and was found to be within the range of 105F and 120F. Continued on 809-C

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:	DATE: 08/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2023

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: MARY'S CHATEAU III	FACILITY NUMBER: 195850361
	VISIT DATE: 08/22/2023

NARRATIVE

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Continued from 809
Resident and staff records are to be stored in a filing cabinet, which is currently located in an office area next to living room. Medications are to be centrally stored in the filing cabinet as well. The first aid supplies were complete , including a thermometer and a current version of a first aid manual. They were stored in the file cabinet as well.

Kitchen knives are stored in a locked cabinet to the right of the fridge. Stove burners are rendered inaccessible to the residents by removing them when not in use. The supply of dishes, utensils, pots, pans and drinkware is adequate. The freezer was maintained at zero degrees Fahrenheit (0*F) and the refrigerator was maintained at 40*F. The supply of nonperishable food is adequate. There are no pesticides (poisons) or toxins stored in any food storage area or preparation area with utensils. Appliances in the kitchen were clean and all appeared functional. Trash cans had tight fitting lids. No flies or other vermin were observed.

The common areas were appropriately furnished, and the lighting was adequate. There is a television and other entertainment equipment, games and/or activity supplies in the living room. There was sufficient space to accommodate both indoor and outdoor activities. Night lights were maintained in hallways and passageways to non private bathrooms. There is a fireplace in the living room that is non-operable at this time. It is screened and there are no tools. Alarms on all exterior doors were engaged at the time of visit and functional.

The facility had emergency exit signs . The facility has a furnace, which is able to heat rooms that residents occupy to a minimum of 68 degrees Fahrenheit; and, they have central air conditioning and are able to cool rooms to a comfortable range, not to exceed 85 degrees Fahrenheit.

The facility smoke alarm system are battery operated. The smoke detector and carbon monoxide detectors were tested and functioned properly during the time of visit. Fire extinguishers were observed fully charged and purchased in August of 2023.

The laundry room is located to the right of the front entry door. Cleaning supplies and toxins were observed stored here and the room will be inaccessible to residents in care.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:	DATE: 08/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2023

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 III	FACILITY NUMBER: 195850361
	VISIT DATE: 08/22/2023

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Continued from 809-C
The supply of extra bed and bath linens is adequate. Personal hygiene items (shampoos, soaps) were adequate and are to be stored inaccessible to residents in care. Extra incontinence supplies are stored in the storage room. There are (3) functioning telephones on the premises. The emergency exiting plans/sketch are posted at the entrance and outside of every room. The emergency telephone numbers are posted on the bulletin board in the office area. Other required postings are posted on the white board as well.

The exterior passageways were clean and clear of any obstructions. There are (2) covered patio areas one (1) at the side of the house with tables and chairs where residents can sit and another area in the front of the house. The entire property is fenced. The gate to the front courtyard has a gate with a self-latching mechanism for persons to enter the front courtyard. LPA observed appropriate furniture for outdoor use. There is no attached garage. There is no storage shed observed at this time. There are no bodies of water on the premises at the present time.

Component III was conducted in conjunction with the visit.

The physical plant was not consistent with the submitted facility sketch/floor plan as the sketch indicated Room #4 was approved for a bedridden resident, however Room #4 does not have a direct exit to outside of the facility. During the visit LPA contacted the Fire Inspector, who stated it was incorrectly notated on the form and confirmed that Room #6 is the room approved for bedridden residents. An updated STD 850 will be provided to the Department.

No corrections required on a pre-licensing visit at this time. Exit interview conducted. Report issued and provided to Licensee.

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.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:	DATE: 08/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2023

LIC809 (FAS) - (06/04)

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