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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197606792
Report Date: 09/07/2023
Date Signed: 09/07/2023 12:44:06 PM

Document Has Been Signed on 09/07/2023 12:44 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
WOODLAND HILLS S.ASC, 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: 5DATE:
09/07/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Veronica Benzonan & Samea HelmandiTIME COMPLETED:
01:00 PM
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Licensing Program Analyst (LPA) Tuesday Cabiness arrived at the facility to conduct an annual inspection. LPA attempted to enter the property but was originally not successfully due to LPA not sure how to enter the property. LPA contacted the phone number on the facility's business sign, which is the number to the Administrator/Licensee Samea Helmandi. LPA called the phone number numerous times, and did not get a response; and could not leave a voice mail, due to it being full. LPA attempted to knock on the front and side entrance of the gate to get staff attention, but was not successful. LPA saw a delivery truck dropping off supplies and inquired how he entered the property. It should be known, to enter the facility, you must enter the property that is adjacent to the corner street, which is the Administrator's family owned property. LPA observed a male individual parking the car to the front of the adjacent property. LPA informed the male my reason for being at the facility, and requested him to contact the owner of the facility. The male individual stated to LPA, that the Administrator/Licensee was his sister. LPA was then greeted by the caregiver, who showed LPA where to enter the facility. After (30) minutes of being inside the facility and conducting a semi-inspection, the Administrator Samea called the facility and informed LPA that she was about (30) minutes away and would be headed to the facility. A complete inspection/tour of the facility was conducted from the inside and outside. The following was observed during the inspection:

Kitchen: LPA observed Licensing requirement of (7) day nonperishable, and (2) perishable, with extra refrigerator located in the staff room. Food was properly wrapped, and appliances were functional, clean, and in good repair. Chemicals, household supplies, and knives, and medication were stored in the kitchen area which was locked and secured. Living/dining: All indoor passageways were free from obstruction; inside temperature was comfortable, with adequate lighting, and all areas were clean and appropriately furnished for resident’s comfort. Bedrooms: The facility has (6) bedrooms; with (1) room for staff. All bedrooms were properly furnished and supplied with appropriate bedding and linens. There were sufficient linens and towels observed and available.
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Tuesday Cabiness
LICENSING EVALUATOR SIGNATURE: DATE: 09/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/07/2023
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
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: LUXOR LIVING
FACILITY NUMBER: 197606792
VISIT DATE: 09/07/2023
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Bathrooms: There are (3); all were clean, with soap and towels, grab bars, and non-skid mats. Hot water measured at 112.4. degrees Fahrenheit. Surrounding Grounds: There were no visible hazards; passageways were free from obstruction and gates were easily accessible to open. The facility has outdoor furniture, with a covered shaded area for residents and visitors. The facility does not have a swimming pool/body of water. Behind or on the side of the facility, there are (2) additional spaces, which is a laundry room and and office. Laundry detergents, cleaning agents and other toxins are stored in laundry room. Fire extinguisher fully charged. First aid kit furnished fully equipped; need current or updated manual. Smoke alarms and carbon monoxide detectors were tested. All exit doors have alarms and working properly.

Record review: A complete record review of staff (2) and residents (2) residents were reviewed. Medication records and training records reviewed. Last fire drill conducted July 2023. All (5) residents and staff are vaccinated; only (1) does not have the booster. All new admits must have a negative COVID test and a current physician report. New hires must be vaccinated.

Exit interview and copy of report.

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Tuesday Cabiness
LICENSING EVALUATOR SIGNATURE:

DATE: 09/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/07/2023
LIC809 (FAS) - (06/04)
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