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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610207
Report Date: 06/16/2022
Date Signed: 06/16/2022 03:45:30 PM

Document Has Been Signed on 06/16/2022 03:45 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:AMORE VILLAFACILITY NUMBER:
197610207
ADMINISTRATOR:MELKONYAN, MARIYAFACILITY TYPE:
740
ADDRESS:8455 SPRINGFORD DRTELEPHONE:
(818) 425-4975
CITY:SUN VALLEYSTATE: CAZIP CODE:
91352
CAPACITY: 6CENSUS: 0DATE:
06/16/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Mariya MelkonyanTIME COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Tuesday Cabiness conducted a PRE-LICENSING visit to the above address 8455 Springford Dr, Sun Valley, CA 91352. LPA met with Administrator Mariya Melkonyan. The inspection included, fire safety, personal accommodations, building and grounds, furniture/equipment, food service, and medication procedures. Fire Inspection was approved on November 17, 2021 which met fire department requirements for (3) shared rooms, which all rooms could have non-ambulatory residents; room # 3, is only allowed for (1) bedridden resident, which includes an exit door. Facility is approved for (6) hospice residents, and Administrator has submitted dementia care plan to the applications unit for review. Facility sketch, emergency disaster plan, complaint procedures, personal rights, emergency exit plan, and other required Licensing were visibly posted. COVID signs, visitor book, and hand washing station observed at the front entrance.

The physical plant was toured inside and out with Administrator Mariya. The facility is a one level home, with (3) shared bedrooms and (1) office for staff, and (2) bathrooms. Each has telephone, and flashlights. There is no staff room. Food supply was inspected and observed, and storage areas, cabinets, pantries, cupboards counters, and refrigerator were clean and appropriate for food preparation. Knives and medication were stored in cabinets located in the kitchen area. Appliances were clean and functional, and utensils, plates, and cups were in good repair. Cleaning supplies, poisons, toxins and chemicals were locked and stored under the sink in the kitchen. There was enough supply of linens and towels, which were stored in a cabinet located in the hallway. Hygiene products were also available, which were locked and secured. LPA observed at least (30) day supply of PPE.

The common areas included the dining, living, bathroom, bedrooms, and staff office. Doors and passageways were clear and unobstructed. Walls, ceilings, floors, window screens and all other rooms were clean, in good repair, and appropriately furnished. Resident rooms

SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Tuesday Cabiness
LICENSING EVALUATOR SIGNATURE: DATE: 06/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/16/2022
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: AMORE VILLA
FACILITY NUMBER: 197610207
VISIT DATE: 06/16/2022
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observed to have a mattress with pad, sheets, pillow, bedspread, dresser, closet space, and chair. Bathrooms were clean had functional fixtures, with soap and towels, grab bars and hand washing signs were posted. The water temperature measured at 111.2 degrees Fahrenheit. The back yard is completely fenced with a gate easily accessible and unlocked. There are no swimming pools or other bodies of water, no visible hazards around the surrounding grounds. Patio furniture available for resident's use.

Smoke detectors and carbon monoxide were hardwired and operating correctly. Fire extinguisher is fully charged. Internet and telephone installation was completed. First aid kit inspected. Staff and client files will be stored in the staff office.

COMP III was completed during the visit and Mitigation plan was discussed.

Exit interview conducted and copy of report provided to Administrator.

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

DATE: 06/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2022
LIC809 (FAS) - (06/04)
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