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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609700
Report Date: 12/12/2022
Date Signed: 12/12/2022 11:37:10 AM

Document Has Been Signed on 12/12/2022 11:37 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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:BRILLIANT SENIOR CARE FACILITYFACILITY NUMBER:
197609700
ADMINISTRATOR:DAVTYAN, ANNAFACILITY TYPE:
740
ADDRESS:16246 VINTAGE STTELEPHONE:
(747) 529-4964
CITY:NORTH HILLSSTATE: CAZIP CODE:
91343
CAPACITY: 6CENSUS: 6DATE:
12/12/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Anna Davtyan - AdministratorTIME COMPLETED:
11:40 PM
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On 12/12/22, Licensing Program Analyst (LPA) Melissa Ruiz arrived at the facility to conduct an unannounced annual inspection. Upon arrival, LPA was greeted by a staff member. LPA observed covid-19 signage, hand sanitizer, and covid-19 signage posted outside. Staff took LPAs temperature and covid-19 infection control questions were asked. Later, LPA met with the Administrator and the purpose of the visit was explained.

LPA initiated a physical plant tour. Facility is a Residential Care Facility for the Elderly which is licensed for five (5) non-ambulatory residents and one (1) bed ridden resident. Facility has five bedrooms, two bathrooms, all designated for resident use. Facility has been approved for a hospice waiver for five (5) residents. LPA was able to tour the home and did not observe any immediate health and safety concerns. Sufficient PPE supplies were observed. The fire extinguisher was observed in the kitchen area and has a date of purchase of 1/26/22. Smoke detectors and carbon monoxide monitors were observed to be functional. LPA observed there to be sufficient stock of one-week non-perishable foods and two-day perishable foods. Sharps, cleaning supplies and medications are centrally stored and are kept locked. Bedrooms are appropriately furnished and have appropriate lighting. Bathrooms have soap, paper towels and hand washing signs were observed. Extra towels and linens were readily available. There is a clean covered shaded area in the back yard and there are no bodies of water.

No deficiencies issued during today’s visit. Report was signed and delivered by Administrator and an exit interview was conducted.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Melissa Ruiz
LICENSING EVALUATOR SIGNATURE: DATE: 12/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/12/2022
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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