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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
197609508
Report Date:
01/19/2024
Date Signed:
01/19/2024 01:41:08 PM
Document Has Been Signed on
01/19/2024 01:41 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
WOODLAND HILLS S.RO
,
21731 VENTURA BLVD., STE. 250
WOODLAND HILLS
,
CA
91364
FACILITY NAME:
MOUNTAIN VILLA
FACILITY NUMBER:
197609508
ADMINISTRATOR:
NARINE SARYAN
FACILITY TYPE:
740
ADDRESS:
1845 W. MOUNTAIN STREET
TELEPHONE:
(818) 945-5644
CITY:
GLENDALE
STATE:
CA
ZIP CODE:
91201
CAPACITY:
6
CENSUS:
5
DATE:
01/19/2024
TYPE OF VISIT:
Case Management - Other
UNANNOUNCED
TIME BEGAN:
12:28 PM
MET WITH:
Narine Saryan, Administrator
TIME COMPLETED:
01:40 PM
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Licensing Program Analyst (LPA) Rosaura Valenzuela conducted an unannounced case management visit for the purpose of determining how many residents in care have dementia and to see if there is a dementia care plan.
LPA interviewed Administrator. Interviews revealed that there is currently one out of the five residents in care with diagnosed dementia. Administrator also showed LPA dementia care plan and provided a copy.
At this time no health and safety issues noted.
Exit interview conducted and a copy of the report was provided.
SUPERVISORS NAME
:
Naira Margaryan
LICENSING EVALUATOR NAME
:
Rosaura Valenzuela
LICENSING EVALUATOR SIGNATURE
:
DATE:
01/19/2024
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
01/19/2024
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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