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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609508
Report Date: 02/28/2025
Date Signed: 02/28/2025 04:50:03 PM

Document Has Been Signed on 02/28/2025 04:50 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 VILLAFACILITY NUMBER:
197609508
ADMINISTRATOR/
DIRECTOR:		NARINE SARYANFACILITY TYPE:
740
ADDRESS:1845 W. MOUNTAIN STREETTELEPHONE:
(818) 945-5644
CITY:GLENDALESTATE: CAZIP CODE:
91201
CAPACITY: 6CENSUS: 7DATE:
02/28/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:50 AM
MET WITH:Reliever, Victoria Chika Atufula & Administrator, Narine Sarovan TIME VISIT/
INSPECTION COMPLETED:
05:15 PM
NARRATIVE
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At 9:50a.m., Licensing Program Analyst (LPA) Antonia Alvizar-Ettima conducted an unannounced Required One (1) year inspection to the facility. LPA met with Reliever and granted entry in the facility. At 10:00 a.m., Administrator arrived and explained the reason for the visit.

At 10:30a.m. LPA and Administrator conducted a tour of the physical plant. There is one entrance being utilized at the facility. Facility is a single-story residence located in a residential neighborhood.

LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:

The facility has a total of five (05) bedrooms and four (04) bathrooms. The facility is fire cleared for six (06) non-ambulatory and a hospice waiver for four (04). The facility is currently occupying seven (07) residents. Last fire drill was conducted on 01/19/2024. The living and dining room are neat and clean. The facility maintains a comfortable temperature at 75°F. The smoke and carbon monoxide detectors are hardwired, interconnected and observed to be operational. Fire extinguisher is located near the kitchen, observed to be full and last purchased on 03/02/2024.


Kitchen is sufficiently stocked with at least two (02) days perishable and seven (07) days non-perishable food. Frozen foods are wrapped and stored appropriately. Food storage and preparation areas are clean and inaccessible to pests. Knives and sharps are observed to be locked and inaccessible to residents.

Residents rooms are adequately furnished with appropriate lighting system. Hallways are well lit. Residents have enough personal hygiene product provided by the licensee.

Cont. on LIC 809-C

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Antonia Alvizar-Ettima
LICENSING EVALUATOR SIGNATURE: DATE: 02/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/28/2025
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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
VISIT DATE: 02/28/2025
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The bathroom was checked for cleanliness and proper operations. The hot water temperature was measured at 115.4°F. Towels and washcloths are not shared. There was enough clean linen available in the cabinets.

The facility has outdoor furniture with a covered shaded area for residents and visitors. The facility has a swimming pool with appropriate locked fence. The shed is currently being used for storage. Laundry detergents, cleaning agents and other toxins are locked away.

LPA observed medication and first aid kit to be locked and inaccessible to residents.

A file review of resident records to ensure compliance of licensing forms.



A file review of staff records to ensure forms and training are up to date and compliance with licensing forms.


Pursuant to Title 22 Division 6 of the CA Code of Regulations, deficiencies observed cited on LIC809-D during the visit.

Exit Interview Conducted / A Copy of the Report was provided to Administrator.

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Antonia Alvizar-Ettima
LICENSING EVALUATOR SIGNATURE:

DATE: 02/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/28/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/28/2025 04:50 PM - It Cannot Be Edited


Created By: Antonia Alvizar-Ettima On 02/28/2025 at 03:31 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: MOUNTAIN VILLA
FACILITY NUMBER: 197609508

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/28/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87204(a)
Limitations -Capacity and Ambulatory Status
(a) A licensee shall not operate a facility beyond the conditions and limitations specified on the license, including specification of the maximum number of persons who may receive services at any one time. An exception may be made in the case of catastrophic emergency when the licensing agency may make temporary exceptions to the approved capacity.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation the licensee did not comply with the section cited above seven (07) residents reside in the facility. Facility's approved capacity is six (06) residents which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/28/2025
Plan of Correction
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At the time of visit one (01) resident moved out of facility and POC has been cleared during today's visit.
Type A
Section Cited
CCR
87355(d)(3)
Criminal Record Clearance
(3) The licensee shall submit these fingerprints to the California Department of Justice, along with a second set of fingerprints for the purpose of searching the records of the Federal Bureau of Investigation, or comply with Section 87355(c), prior to the individual's employment, residence, or initial presence in the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above staff (S1) is not Criminal Background Clearanced and Associated to this facility which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/28/2025
Plan of Correction
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At the time of visit staff (S1) exit the facility with staff and will not return. POC has been cleared during today's visit.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Naira Margaryan
LICENSING EVALUATOR NAME:Antonia Alvizar-Ettima
LICENSING EVALUATOR SIGNATURE:
DATE: 02/28/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/28/2025


LIC809 (FAS) - (06/04)
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