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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608585
Report Date: 03/09/2022
Date Signed: 03/09/2022 04:24:24 PM

Document Has Been Signed on 03/09/2022 04:24 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, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:BUENA VISTA VILLA RCFEFACILITY NUMBER:
197608585
ADMINISTRATOR:GAYANE DZHAGARYANFACILITY TYPE:
740
ADDRESS:2741 N. BUENA VISTA STREETTELEPHONE:
(818) 478-1357
CITY:BURBANKSTATE: CAZIP CODE:
91504
CAPACITY: 6CENSUS: 5DATE:
03/09/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:08 AM
MET WITH:Michael Petrosian, Assiistant Administrator TIME COMPLETED:
04:27 PM
NARRATIVE
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Licensing Program Analyst (LPA) Alberto Lopez conducted an unannounced Required- 1-year visit focusing on COVID-19 Infection Control Practices. LPA was greeted by Geghettsik Ishagharyan, Caregiver and House Manager Harut Sargian, and Assistant Administrator Michael Petrosian arrived a short time later and LPA explained the purpose of the visit. Administrator certificate expires 09/10/2022 Last fire drill was on 03/01/2022
Structure:
The Facility is a single storey building in a residential area with 3 shared resident bedrooms and there’s 1 dining room, 2 full bathrooms, a kitchen. A laundry room, and a family room. There is a large garden area on the back premises with tables and chairs and shade. All the resident’s bedrooms are spacious and will easily accommodate the resident's furnishings. The passageway and walkways are free of hazard and free from obstruction.

The following were observed/inspected:
· COVID-19 signs are posted at the entrance. Visitors are screened in the main entrance and a log is kept.
· Water temperature measured between 105 – 120 degrees F which is within regulation range.
· Infection control signs and other COVID-19 signs are posted throughout the facility in the bathrooms, kitchen, and hallway to promote handwashing, cough/sneeze etiquette, and physical distancing.
· Facility does not has one designated isolation room. Facility Assistant Administrator will put them up in hotel room or send them to alternate home.
· Three client rooms, common areas, bathrooms, and outdoor physical plant was inspected.
· Three client rooms were equipped with alcohol-based hand sanitizer.
· Five (5) centrally stored client medication records were reviewed.
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SUPERVISORS NAME: Christine Yee
LICENSING EVALUATOR NAME: Alberto Lopez
LICENSING EVALUATOR SIGNATURE: DATE: 03/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/09/2022
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, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: BUENA VISTA VILLA RCFE
FACILITY NUMBER: 197608585
VISIT DATE: 03/09/2022
NARRATIVE
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· Staff responsible for direct care and supervision were observed wearing masks.
· Clients were not observed wearing masks but adhering to public health social distance guidelines.
· Sufficient supply of perishable food for 2 days & non-perishable foods for 7 days were observed.
· A posted Emergency Disaster Plan was observed posted at facility.
· PPE's were observed.
· Staff and resident files were not reviewed during today's visit.
· Deficiencies were observed during today’s visit. (please see 809D)

· Exit interview was conducted with Assistant Administrator Michael Petrosian. A copy of the report was provided.
SUPERVISORS NAME: Christine Yee
LICENSING EVALUATOR NAME: Alberto Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 03/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/09/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/09/2022 04:24 PM - It Cannot Be Edited


Created By: Alberto Lopez On 03/09/2022 at 04:06 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: BUENA VISTA VILLA RCFE
FACILITY NUMBER: 197608585

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/09/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
Deficient Practice Statement
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80087(a) Buildings and Grounds. LPA Observed window in bathroom #1 in disrepair. It will not stay up on its own. Also window screen in same bathroom is in disrepair and needs to be replace,
POC Due Date: 04/09/2022
Plan of Correction
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Administrator will repair window and replace screen by POC date and send photo to LPA.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Christine Yee
LICENSING EVALUATOR NAME:Alberto Lopez
LICENSING EVALUATOR SIGNATURE:
DATE: 03/09/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/09/2022


LIC809 (FAS) - (06/04)
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