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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609508
Report Date: 07/08/2023
Date Signed: 07/08/2023 10:59:24 AM

Document Has Been Signed on 07/08/2023 10:59 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:MOUNTAIN VILLAFACILITY NUMBER:
197609508
ADMINISTRATOR:NARINE SARYANFACILITY TYPE:
740
ADDRESS:1845 W. MOUNTAIN STREETTELEPHONE:
(818) 945-5644
CITY:GLENDALESTATE: CAZIP CODE:
91201
CAPACITY: 6CENSUS: 6DATE:
07/08/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:40 AM
MET WITH:Narine Saryan-AdministratorTIME COMPLETED:
11:00 AM
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On 7/8/2023, Licensing Program Analyst (LPA) Alfonso Iniguez conducted an unannounced annual required using the CARE Inspection Tool. LPA met with Naryn Sarian/Administrator. LPA explained the purpose of today’s visit. The facility is licensed to serve (6) residents ages 60 and above. (6) non-ambulatory. Facility has an approved hospice waiver for (4) patients.

Facility is a single-story residence located in a residential neighborhood. It consists of four (4) bedrooms, (2) of the bedrooms are resident rooms. Living room, Dining room, kitchen. There is a large, covered patio area with swimming pool that is situated behind a secured locked fence. The back-patio area has furniture for the resident’s leisure.

LPA Iniguez toured the physical plant with administrator. There were no obstructions on the premises. A total of (3) rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, and storage for the resident’s personal belongings was observed. Bathrooms were found to be within Title 22 regulations and were operational. Cleaning solutions are locked in luandry room. LPA inspected rooms: #1, #2, and #3 and smoke and carbon monoxide combo are all operable conditions. The water temperature properly measured between 105°-120°F: Kitchen 107.3°F, Bathroom #1:108.2°F & Bathroom #2: 109.2°F.

Evaluation Report Continues LIC 809-C

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE: DATE: 07/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/08/2023
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: MOUNTAIN VILLA
FACILITY NUMBER: 197609508
VISIT DATE: 07/08/2023
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LPA Iniguez observed the facility to be sanitary and appropriately furnished at the time of the 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. All fire extinguishers were charged and were operable. Working landline phones are available on-site. A review of (3) residents' service files (R1-R3) and (2) staff personnel files (S1-S2) and Medication Administration Records (MAR) were maintained in order. First AID kit was checked.

LPA observed the facility's infection control practices.

According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA did not observe deficiencies therefore no citations were issued at this time.



An exit interview was conducted and a copy of the Facility Evaluation Report was provided to Narine Saryan-Administrator.
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE:

DATE: 07/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2023
LIC809 (FAS) - (06/04)
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