197607871-3-5-2025-31-AS-NSHN-DEH2ZN-20250305165038

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197607871
Report Date: 03/05/2025
Date Signed: 03/05/2025 04:50:56 PM

Document Has Been Signed on 03/05/2025 04:50 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.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	A BURBANK RESIDENTIAL CARE		FACILITY NUMBER:	197607871
ADMINISTRATOR/ DIRECTOR:	GAYANE DZHAGARYAN		FACILITY TYPE:	740
ADDRESS:	2020 SCOTT ROAD		TELEPHONE:	(818) 588-3916
CITY:	BURBANK	STATE: CA	ZIP CODE:	91504
CAPACITY: 6		CENSUS: 4	DATE:	03/05/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:30 AM
MET WITH:	Levon Chalabyan - Administrator		TIME VISIT/ INSPECTION COMPLETED:	04:31 PM

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Licensing Program Analyst (LPA) Nadia Shahbazian conducted an unannounced Required - 1 Year annual inspection visit. Upon arrival at 9:30am, LPA met with Direct Service Provider (DSP)/Anahit Zalinyan. LPA explained the purpose of the visit. Administrator/Levon Chalabyan arrived at 10:10 am. The program is vendorized through the Frank D. Lanterman Regional Center. The Adult Residential Facility is licensed for six (06) non-ambulatory with a hospice waiver for one (01). Current census is four (4) ambulatory residents.

LPA toured the facility with the Administrator at 10:30 am and observed the following:

Required postings were observed by the entry area. The front entry is the main exit door with three (3) additional exits (by the kitchen, room# 2 and in the dining room) leading to the backyard. The physical plant appeared clean, sanitary and with no visible immediate hazards. There are two (2) fire extinguishers, one (1) in the kitchen, one (1) in the hallway. Both fire extinguishers were fully charged on 05/06/2024. Facility conducts bimonthly fire and safety drills, the last fire drill was conducted on 01/03/25. LPA reviewed the facility liability insurance which expires on 12/06/2025. The dual smoke alarms and carbon monoxide detectors are hardwired and interconnected. At 10:49 am the smoke/carbon monoxide alarms were tested and observed to function properly.

(Continued on 809C)

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Nadia Shahbazian
LICENSING EVALUATOR SIGNATURE:	DATE: 03/05/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/05/2025

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 S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: A BURBANK RESIDENTIAL CARE	FACILITY NUMBER: 197607871
	VISIT DATE: 03/05/2025

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Common Areas: Include a living room, dining room and breakfast nook in the kitchen. The office area is located near the entrance/dining area. Dining room is furnished with a table and ten (10) chairs. A properly covered screen covered the non-functional fireplace in the dining room. The living room had a table and ample sitting for all the residents and staff. Television set and activity/gaming areas were observed in the living room.

Kitchen: There is a refrigerator, stove, macrowave and toaster oven in the kitchen with a breakfast nook with table/chairs for six clients. Knives, cutlery and other sharp kitchen utensils are stored and locked in the kitchen cabinet. Food storage and preparation areas are clean and sanitary. LPA found a sufficient amount of perishable and non-perishable food supplies, properly stored in locked storages in the kitchen and also in the garage.

Laundry Room: Laundry machines were located near the kitchen halway. All laundry detergents/chemicals and kitchen cleaners are stored in a locked cabinet in the laundry area, inaccessible to clients in care.

First-Aid Kit/Medications: All medications were observed to be locked in a hallway cabinet. In the same cabinet, LPA observed two (2) complete first-aid kits with all required supplies and the first aid manual.

Bathrooms: There are two (2) full bathrooms for the residents and one (1) half bathroom for staff. All toilets and sinks are maintained in sanitary, operating condition. Functional grab bars and non-slip mats were observed in resident bathrooms. Hot water temperature was tested between 112.8 - 113.2 degrees Fahrenheit.

(Continued on 809-C)

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Nadia Shahbazian
LICENSING EVALUATOR SIGNATURE:	DATE: 03/05/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/05/2025

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 S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: A BURBANK RESIDENTIAL CARE	FACILITY NUMBER: 197607871
	VISIT DATE: 03/05/2025

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Bedrooms: There are six (6) bedrooms. Bedrooms designated for clients' use are #2,3,4,5. All of the bedrooms were properly furnished with appropriate chairs, beddings, chest drawers, linens with sufficient lighting. All client bedrooms are currently furnished for single occupancy (5 total). A live-in staff is currently using bedroom for clients as staff quarters. The administrator will ensure no staff will use client bedrooms. Bedroom #3 will be furnished for double occupancy, to be used for residents only. Bedroom#1 will be used for staff room.

Surrounding grounds: Entry/exit gates and pathways were free of obstruction. The outdoor area was free of visible immediate hazards. No bodies of water were observed at the facility. There is ample patio space for outdoor activities. There was a shaded patio area with furniture appropriate for outdoor use sufficient for all clients. Facility has a detached garage which currently is used as storage. LPA observed two (2) refrigerators supplied with labeled perishable food items. LPA also observed chemicals and gardening tools, locked in the garage.

At 3:05 pm, LPA initiated a review of facility Staff and Client files.

Resident Files: A review of resident records to ensure compliance of licensing forms was conducted. Medications records for residents were also verified for accuracy of administration based on physician orders. Resident P&I and medications were reviewed.

Staff Files: Staff files were reviewed to ensure all forms and training certificates are up to date.

Pursuant to Title 22 Division 6 of the CA Code of Regulations, no deficiencies observed during the visit.

Exit Interview Conducted / A Copy of the Report provided to Administrator.

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Nadia Shahbazian
LICENSING EVALUATOR SIGNATURE:	DATE: 03/05/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/05/2025

LIC809 (FAS) - (06/04)

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