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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197606792
Report Date: 08/18/2022
Date Signed: 08/18/2022 11:37:18 AM

Document Has Been Signed on 08/18/2022 11:37 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., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:LUXOR LIVINGFACILITY NUMBER:
197606792
ADMINISTRATOR:SAMEA HELMANDIFACILITY TYPE:
740
ADDRESS:17835 PARTHENIA STREETTELEPHONE:
(818) 687-6877
CITY:NORTHRIDGESTATE: CAZIP CODE:
91325
CAPACITY: 6CENSUS: 4DATE:
08/18/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Samea Helmandi TIME COMPLETED:
11:45 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
On 08/18/22 Licensing Program Analyst (LPA) Joscelyn Martinez arrived at the facility to conduct an unannounced annual inspection. Upon arrival LPA met with staff and then met with Administrator Samea Helmandi. The purpose of the visit was explained. Entrance interview conducted.

A physical plant tour was conducted at 10:00 a.m and the following were observed:

Infection Control: Covid-19 infection control signage were observed outside of the facility. Proper signage was also observed inside in the common areas. Staff screened LPA for covid symptoms and took LPA’s temperature. Facility has sufficient PPE supplies for more than 30 days. Food Inspection/Kitchen: LPA observed there to be sufficient stock of one-week non-perishable foods and two-day perishable foods. Food storage and preparation areas are clean and inaccessible to pests. Garbage cans have tight fitting covers in the kitchen. Sharps are centrally stored in a locked area. Medication are centrally stored in a locked cabinet in the kitchen area. Chemicals are stored underneath the sink in a lock cabinet. Smoke detectors/carbon monoxide are located throughout the facility and are dual hardwired. Smoke detectors and carbon monoxide detectors were tested at approximately 10:45 a.m. and were observed to be functional. Fire extinguisher has a purchase date of 11/21//2021. Common Areas: All common areas were observed to be clean and properly furnished. LPA observed activities in the common areas. Resident Rooms: Facility has six (6) bedrooms which of five are designated for resident use. Facility has two live-in staff. All six (6) bedrooms were toured and appear to be clean and properly furnished. LPA observed additional bedding and linens sufficient for all of the residents. All rooms have adequate lighting and furniture. Bathrooms: There are three (3) bathrooms in the facility of which two (2) are designated for resident’s use. LPA observed all bathrooms to be cleaned. The hot water was tested and measured 105.2 F, which is in regulation. All trash cans located in the bathrooms have tight fitting lids. (Continue on 809-C)

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Joscelyn Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 08/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/18/2022
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., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: LUXOR LIVING
FACILITY NUMBER: 197606792
VISIT DATE: 08/18/2022
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
Outside: LPA toured the outside area and observed appropriate outdoor furniture with a shaded covered area for residents. There is a subdivision house on the property in where the residents do not have accesses. There are no bodies of water.

No deficiencies cited. Exit interview conducted. Report signed and delivered. Appeal rights delivered.

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Joscelyn Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 08/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2