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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609771
Report Date: 03/20/2025
Date Signed: 03/20/2025 03:49:45 PM

Document Has Been Signed on 03/20/2025 03:49 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 N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:ETERNAL LIFE SENIOR CARE FACILITYFACILITY NUMBER:
197609771
ADMINISTRATOR/
DIRECTOR:		AVETIKYAN, OLGAFACILITY TYPE:
740
ADDRESS:8112 CROSNOE AVENUETELEPHONE:
(818) 988-7878
CITY:VAN NUYSSTATE: CAZIP CODE:
91402
CAPACITY: 6CENSUS: 2DATE:
03/20/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:52 AM
MET WITH:Viktorya HayrapetyanTIME VISIT/
INSPECTION COMPLETED:
02:28 PM
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Licensing Program Analyst (LPA) Sandra Urena arrived at the facility unannounced to conduct a required annual visit. At 10:57 a.m., the LPA met with staff and explained the reason for the visit. Staff Viktorya Hayrapetyan arrived at the facility shortly thereafter. The Administrator was not available during the time of the visit and authorized staff Viktorya Hayrapetyan to sign the report.

At 11:15 a.m., the LPA, along with staff, toured the physical plant areas inside and outside to ensure there are no health and safety hazards and that the facility is in compliance with Title 22 Regulations.

KITCHEN: The LPA observed the kitchen and dining area. Knives are stored in a locked kitchen cabinet. Kitchen appliances are in operable condition. The facility has a sufficient supply of perishable and non-perishable food. At 11:51 a.m., hot water measured at 105.2-degree Fahrenheit. Laundry units, cleaning solutions, chemicals and hazardous items were inaccessible and locked away inside the staff/ storage room. Emergency water was also located in the staff/ storage room. First aid kit was observed in the kitchen. Medications are located in a locked kitchen cabinet.

COMMON AREAS: The LPA observed common areas to be relatively clean and properly furnished. The LPA observed the fire extinguisher to be fully charged and last purchased on 03/28/2024. At 12:00 p.m., fire alarms/carbon monoxide detectors were tested and functioned properly. Facility telephone was observed during the time of the visit. Flashlights and night lights were observed throughout the facility.
Continued on LIC 809-C...
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Sandra Urena
LICENSING EVALUATOR SIGNATURE: DATE: 03/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/20/2025
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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: ETERNAL LIFE SENIOR CARE FACILITY
FACILITY NUMBER: 197609771
VISIT DATE: 03/20/2025
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BEDROOMS: The facility is a single-story residential home with four (4) bedrooms for resident use. The LPA observed resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. Inside temperature was maintained at a comfortable level.

RESTROOMS: Restrooms are relatively clean and sanitary and in operating condition with grab bars and non-skid mats. Hot water measured at 108.0-degree Fahrenheit. The sinks had sufficient liquid soap, and paper towels. Signs are posted throughout the facility restrooms to promote handwashing.

OUTDOOR SPACE: The back patio has a covered outdoor area for resident use. Passageways were free and clear from obstruction. There are no bodies of water on the premises. There is a gate at the front of the facility designated for an emergency exit.



RECORDS: Residents’ records were reviewed for, but not limited to care plans, medical records, admissions agreement, consent forms. All records were in order. Personnel records were reviewed for, but not limited to health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All files were in order.

MEDICATIONS: Medications are centrally stored and locked in a cabinet in the kitchen area; medications are labeled and checked for expiration dates. Medications are properly documented on the centrally stored medications and destruction record. No errors observed during the medication review.

The LPA reviewed the following documents:


- LIC500 Personnel Report
- LIC9020 Client Roster
- Certificate of Liability of Insurance
_ Emergency Drill Logs


No citations were issued. Exit interview conducted. A copy of the report was issued.
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Sandra Urena
LICENSING EVALUATOR SIGNATURE:

DATE: 03/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2025
LIC809 (FAS) - (06/04)
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