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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608963
Report Date: 10/12/2024
Date Signed: 10/12/2024 10:50:28 AM

Document Has Been Signed on 10/12/2024 10:50 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
Lookup Error,
, CA
FACILITY NAME:HAMPTON VILLAFACILITY NUMBER:
197608963
ADMINISTRATOR/
DIRECTOR:		MICHAEL PETROSIANFACILITY TYPE:
740
ADDRESS:706 HAMPTON ROADTELEPHONE:
(818) 433-7266
CITY:BURBANKSTATE: CAZIP CODE:
91504
CAPACITY: 6CENSUS: 6DATE:
10/12/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Michael PetrosianTIME VISIT/
INSPECTION COMPLETED:
11:07 AM
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On 10/12/24, Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with administrator Michael Petrosian and explained the purpose of today’s visit. The facility is licensed to operate for six (6) non-ambulatory. The facility is approved for (3) hospice residents. Currently, the facility has (0) residents in hospice care. The residents are Lanterman Regional Center consumers.

The facility is a single-story structure located in a residential neighborhood. It consists of the following: three (3) resident's rooms, two (2) common bathrooms, a living area, a dining area, a kitchen, an outside covered patio area, and garage used for storage.

LPA and administrator toured the physical plant. There were no bodies of water or obstructions on the premises. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, storage for resident personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. Bathrooms were found to be within Title 22 regulations and were clean and operational. The water temperature measured 107.0-degree F. A comfortable temperature of 72 degree was maintained in the facility.

LPA observed the facility to be clean, sanitary, and appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to residents. The kitchen was inspected and there is sufficient perishable and non-perishable food available maintained properly. Fire extinguishers were charged, smoke detectors and carbon monoxide were operable. A review of the Medication Administration Record (MAR) was complete and accurate. The facility has conducted a disaster drill on 10/01/24. A landline telephone was in working condition. A review of staff CPR/First Aid training is current.

Evaluation Report Continues LIC 809-C
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE: DATE: 10/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/12/2024
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
Lookup Error,
, CA
FACILITY NAME: HAMPTON VILLA
FACILITY NUMBER: 197608963
VISIT DATE: 10/12/2024
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During the visit, LPA observed the facility's infection control practices. LPA observed screening protocols for visitors, staff, and residents, and sanitizing stations in common areas and restrooms. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted.

LPA observed First Aid Kit was maintained. The facility has current liability insurance on file effective 04/01/24 – 04/01/25. The facility is current on Community Care Licensing annual dues.

An audit of residents #1-#6 (R1-R6) service files and staff #1-#3 (S1-S3) personnel files revealed to be complete. The facility has the current administrator's certification on file for Michael Petrosian #7035389740 Exp. 08/10/25.

No deficiencies during this inspection visit.

An exit interview was conducted with Michael Petrosian, and a copy of the report was provided.
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:

DATE: 10/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2024
LIC809 (FAS) - (06/04)
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