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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609759
Report Date: 07/28/2022
Date Signed: 07/28/2022 05:56:13 PM

Document Has Been Signed on 07/28/2022 05:56 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, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:7 HILLS SENIOR LIVINGFACILITY NUMBER:
197609759
ADMINISTRATOR:SIMITYAN, ARMENUIFACILITY TYPE:
740
ADDRESS:7112 OWENS STTELEPHONE:
(818) 438-8613
CITY:TUJUNGASTATE: CAZIP CODE:
91042
CAPACITY: 6CENSUS: 4DATE:
07/28/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
04:45 PM
MET WITH:Gayane Martirosyan & Armenui SimityanTIME COMPLETED:
06:00 PM
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Licensing Program Analyst (LPA) Tuesday Cabiness arrived to conduct an unannounced infection control inspection/visit. LPA was greeted by caregiver Gayane, who allowed LPA to enter the facility. LPA observed residents watching television in the living room. Upon entering the facility, there was no routine symptom screening by the caregiver, and LPA was not requested to sign in the visitor’s book. Caregiver Administrator who arrived sometime later. Administrator reported to LPA, that there have not been any active or past COVID cases at the facility. There current census is (4), and only (3) residents vaccinated; and one resident refused. Department of Public Health contacted Administrator to conduct booster shots for residents. LPA observed hand sanitizing station, and PPE were located at the front door. LPA observed Licensing, Department of Public Health, CDC and other COVID-19 related postings.

The infection control inspection was conducted throughout the facility. The facility has (4) bedrooms; with (2) shared room and (2) private rooms. Beds were kept (6) feet apart. All common areas were observed to be clean, including bathrooms, that had soap and towels. There were hand, washing signs observed in bathrooms. LPA conducted a mitigation plan review with the Administrator, to obtain information on how the facility has implemented the plan. Administrator only conduct COVID-19 testing when symptoms occur. Daily temperature for residents is performed daily. Visitation is conducted in resident’s rooms or outside on the back patio. Residents eat together and practice social distancing at the dining room table. Administrator informed LPA, she received the PINs from the department, and conducts training to staff in relation to COVID-19. There are designated rooms for potential positive COVID residents. PPE, chemicals, cleaning supplies, and paper products are stored in the garage area, which was locked and secured. LPA observed a (30) day supply of PPE, soap and paper products.

SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Tuesday Cabiness
LICENSING EVALUATOR SIGNATURE: DATE: 07/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/28/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: 7 HILLS SENIOR LIVING
FACILITY NUMBER: 197609759
VISIT DATE: 07/28/2022
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LPA observed the facility has Licensing requirement for food supply. Currently, the facility has sufficient staff, and has back-up staff if needed. The facility has not had any positive COVID-19 reports for staff or residents. Administrator informed LPA that they continue to implement the best practices for their facility; which has kept them COVID-19 free. Staff have been trained and notified regarding sick and return to work policies. The facility is aware to report any changes with residents and staff to Licensing and there LPA, pertaining to positive COVID-19 cases.

Exit interview conducted Administrator.

SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Tuesday Cabiness
LICENSING EVALUATOR SIGNATURE:

DATE: 07/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2022
LIC809 (FAS) - (06/04)
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