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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608963
Report Date: 09/01/2021
Date Signed: 09/02/2021 06:40:54 AM

Document Has Been Signed on 09/02/2021 06:40 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, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:HAMPTON VILLAFACILITY NUMBER:
197608963
ADMINISTRATOR:DZHAGARYAN, GAYANEFACILITY TYPE:
740
ADDRESS:706 HAMPTON ROADTELEPHONE:
(818) 433-7266
CITY:BURBANKSTATE: CAZIP CODE:
91504
CAPACITY: 6CENSUS: 5DATE:
09/01/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Staff #1 (S-1)TIME COMPLETED:
12:15 PM
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Licensing Program Analyst (LPA) Elizabeth Irra conducted an unannounced Required-1 year visit focusing on COVID-19 Infection Control Practices. LPA was allowed entry by Staff #1 (S-1) and explained the purpose of today's visit.

This home consists of 3 bedrooms, 2 bathrooms, living room and dinning area. It has a detached garage. All (5) Residents receive case management services provided by Frank D Lanterman Regional Center.

The following were observed/inspected:
  • COVID-19 Infection Control Practices (including signs) were observed at the entrance of this facility, in all common rooms and hallways.
  • Signs are posted throughout the facility to promote hand washing, cough/sneeze etiquette, and physical distancing.
  • All (5) Residents are fully vaccinated.
  • Per caregiver all staff are fully vaccinated.
  • 30 day supply of medication reviewed for (3) residents (Resident #1 through Resident #3)
  • PPE supplies observed inside the home and more stored inside the garage.
  • Incontinence supplies observed inside the home and more stored inside the garage.
  • Sufficient supply of perishable for 2 days and non-perishable foods for 7 days were observed.
  • Residents were socially distanced according to local public health guidelines.

Exit interview conducted, a copy of this report and Appeal Rights were provided to caregiver.
SUPERVISORS NAME: Christine Yee
LICENSING EVALUATOR NAME: Elizabeth Irra
LICENSING EVALUATOR SIGNATURE: DATE: 09/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/01/2021
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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