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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609357
Report Date: 01/31/2022
Date Signed: 01/31/2022 04:06:12 PM

Document Has Been Signed on 01/31/2022 04:06 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:BIRMINGHAM VILLAFACILITY NUMBER:
197609357
ADMINISTRATOR:LEKHLYAN, ANAHITFACILITY TYPE:
740
ADDRESS:825 BIRMINGHAM RDTELEPHONE:
(818) 859-7777
CITY:BURBANKSTATE: CAZIP CODE:
91504
CAPACITY: 6CENSUS: 6DATE:
01/31/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Staff Susanna Hayrapetyan and
Administrator Christine Lekhlyan
TIME COMPLETED:
04:15 PM
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Licensing Program Analyst (LPA) Nune Margaryan conducted an unannounced Required One (1) year - Inspection to this facility. Upon arrival, LPA met with staff Susanna Hayrapetyan who assist with the visit. Shortly after Administrator Christine Lekhlyan arrived. The purpose of the visit was explained. The facility is licensed to serve 6 (six) non-ambulatory residents. Hospice Waiver for (3) three residents. Residents receive services from the Frank D. Lanterman Regional Center.
LPA used the infection control tool to evaluate the facility. LPA inspected the physical plant, COVID-19 procedures, reviewed residents' medications, observed food supply, and reviewed residents and staff files. Facility has submitted a mitigation plan and the plan has been approved.

Facility is located in a residential neighborhood and consists of (6) six resident bedrooms, (1) one staff bedroom, (3) three bathrooms, kitchen, living room, dining room, laundry room area, office area.

LPA toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. LPA observed that the facility does not have a swimming pool or other bodies of water. All indoor and outdoor passageways are free of obstruction.

There is only one entrance being utilized at the facility, all required posters were posted at the entrance. Screening area is located immediately upon entrance. Sign in sheet, hand sanitizer, gloves and masks are available. LPA was screened upon entry. All staff were observed to be wearing mask during this visit.



Resident bedrooms and bathrooms were toured. All bedrooms were sanitary and furnished with required furnitures. Bathrooms have the required grabs bars and non-skid mats. The hot water temperature was tested throughout the facility and maintained within the required range of 105-120*F.

Continued 809C

SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Nune Margaryan
LICENSING EVALUATOR SIGNATURE: DATE: 01/31/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/31/2022
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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: BIRMINGHAM VILLA
FACILITY NUMBER: 197609357
VISIT DATE: 01/31/2022
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The kitchen was inspected. All appliances were operating properly. There was a sufficient amount of perishable and non-perishable food. Kitchen sharps and chemicals are stored in a locked kitchen cabinets.
Common areas were observed clean and properly furnished. Smoke detectors and carbon monoxide detectors are operable and in compliance. The fire extinguishers observed to be fully charged.

The front and back yards are both well landscaped. A shaded area with chairs is available in the patio located on the side of the home. LPA also checked First Aid Kit which was fully stocked with current manual. All medications for residents are centrally stored and inaccessible to residents.

Resident files were reviewed to confirm emergency contact is updated and residents have health screenings and or vaccinations. Staff files were reviewed to confirm health screenings and fingerprint clearances. Residents' medications were reviewed to confirm medication is given as prescribed and is documented properly.



Per California Code of Regulations, Title 22, and California Health and Safety Code, there were no deficiencies observed during the visit. Exit interview held. A copy of the report was provided.
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Nune Margaryan
LICENSING EVALUATOR SIGNATURE:

DATE: 01/31/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2022
LIC809 (FAS) - (06/04)
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