195850542-10-16-2024-29-AS-TBYE-DA4NYX-20241016105328

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 195850542
Report Date: 10/16/2024
Date Signed: 10/16/2024 10:54:23 AM

Document Has Been Signed on 10/16/2024 10:54 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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	ROSE GARDEN SENIOR HOUSING		FACILITY NUMBER:	195850542
ADMINISTRATOR/ DIRECTOR:	TONOYAN, LILIT		FACILITY TYPE:	740
ADDRESS:	7526 TROOST AVENUE		TELEPHONE:	(818) 601-3232
CITY:	NORTH HOLLYWOOD	STATE: CA	ZIP CODE:	91605
CAPACITY: 6		CENSUS: 0	DATE:	10/16/2024
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:46 AM
MET WITH:	Lilit Tonoyan		TIME VISIT/ INSPECTION COMPLETED:	11:00 AM

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) Trevor Byrne conducted a pre-licensing visit to the above noted facility at 08:46 AM. The LPA met with applicant, Avag Petrosyan and administrator Lilit Tonoyan. 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 08:49 AM, a physical plant tour was conducted inside and out. An approved fire clearance was received, clearing them for five (5) non-ambulatory residents; and, one (1) of bedridden resident. The facility has four (4) private resident bedrooms, Rooms # 1, 2, 3, and 5 and one (1) shared room, Room # 4. Bedroom # 3 has a direct exit to the outside and is the bedridden approved room. 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 linens; which includes, a mattress pad, top and bottom linens, pillowcases, blanket 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 are no staff rooms at the facility, awake night staff are required. All rooms were free of odors. LPA observed the window screens in bedrooms # 2, 3, and 5 to be ripped. There are three (3) bathrooms in the facility all are designated as resident bathrooms. All resident bathrooms have a shower with non-skid materials. All toilets and showers have grab bars and all were properly secured. The hot water temperature was measured as follows: bathroom #1 = 116.6 F, bathroom #2 = 118.6 F, bathroom #3 = 117.4 F, which falls within the allowable range of 105 F to 120 F. Resident and staff records are stored in cabinet which is currently located in the staff office. Medications are centrally stored in a locked cabinet in the staff office. The first aid supplies were complete, including a thermometer and a current version of a first aid manual. They were stored in a cabinet in the staff office. Continued on 809 C.

SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Trevor Byrne
LICENSING EVALUATOR SIGNATURE:	DATE: 10/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/16/2024

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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: ROSE GARDEN SENIOR HOUSING	FACILITY NUMBER: 195850542
	VISIT DATE: 10/16/2024

NARRATIVE

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Kitchen knives and other sharp objects are stored in a locked drawer in the kitchen. 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 thirty-five degrees Fahrenheit (35 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. Kitchen, laundry and house cleaning supplies are stored in locked cabinets located under the kitchen sink, in a secured cabinet in the hallway, and in a secured cabinet in the staff office. No flies or other vermin were observed.

The common areas were appropriately furnished, and the lighting was adequate. There are televisions and other entertainment equipment, and activity supplies in the living room. There was sufficient space to accommodate both indoor and outdoor activities. Night lights were maintained in all hallways and passageways to nonprivate bathrooms. Inclines, ramps and open porches and areas of potential hazard to residents with poor balance or eyesight were equipped with sturdy hand railings and were well-lighted. All ramps were secure and non-slippery and were positioned at the level where wheelchairs and walkers may enter and exit the facility safely. There is an electric fireplace in the living room. It is appropriately screened and there are no tools. Alarms on all exterior doors were engaged at the time of visit and functional. In addition, the physical plant is consistent with the submitted facility sketch/floor plan. The facility had emergency lighting, which included flashlights, or other battery powered lighting, and batteries. 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 is hard wired. The smoke detector and carbon monoxide detectors were tested and functioned properly during the time of visit. Both facility fire doors were observed to properly close at the time of the test. There is one (1) fire extinguisher the house located on the kitchen wall. It is fully charged and does not exceed the expiration date.

Continued on 809 C.

SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Trevor Byrne
LICENSING EVALUATOR SIGNATURE:	DATE: 10/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/16/2024

LIC809 (FAS) - (06/04)

Page: 2 of 3

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: ROSE GARDEN SENIOR HOUSING	FACILITY NUMBER: 195850542
	VISIT DATE: 10/16/2024

NARRATIVE

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The laundry area is located in the hallway of the facility. The supply of extra bed and bath linens is adequate. Personal hygiene items shampoos, soaps were adequate and are stored in the resident bathrooms. Extra incontinence supplies are stored in a cabinet located in the staff office. There is a functioning telephone on the premises. The emergency exiting plans/sketch are posted in each resident room and in the hallways. The emergency telephone numbers are posted on the wall in the dining area. Other required postings are posted on the common room walls.

The exterior passageways were clean and clear of any obstructions. There is a covered patio area at the front of the house with tables and chairs where residents can sit. The entire property is fenced. The gate to the driveway is moved automatically. There is a gate at the front entrance of the property that does not self latch. There is a locked storage shed in the back yard that contains lawn care tools and maintenance supplies. There are not any bodies of water on the premises at the present time. The garage is not accessible from the house; the doors were locked.

COMP III orientation was conducted with the applicant. Applicant expressed understanding of the material covered. The following items must be corrected prior to licensure. Submit proof of corrections, along with a copy of this report, to LPA Byrne so that your application may be completed.

87303(c) - All window screens shall be clean and maintained in good repair.

87705(h) - Outdoor facility space used for resident recreation and leisure shall be completely enclosed by a fence with self-closing latches and gates, or walls, to protect the safety of residents.

This report will be sent to the Centralized Application Bureau (CAB) once all corrections are received. 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: Kasandra Lopez
LICENSING EVALUATOR NAME: Trevor Byrne
LICENSING EVALUATOR SIGNATURE:	DATE: 10/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/16/2024

LIC809 (FAS) - (06/04)

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