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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610255
Report Date: 05/23/2022
Date Signed: 05/27/2022 02:43:53 PM

Document Has Been Signed on 05/27/2022 02:43 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:AMAZING SENIOR CARE ON LASSEN, INC.FACILITY NUMBER:
197610255
ADMINISTRATOR:ALADADYAN, YELENAFACILITY TYPE:
740
ADDRESS:17127 LASSEN STTELEPHONE:
(818) 207-4220
CITY:NORTHRIDGESTATE: CAZIP CODE:
91325
CAPACITY: 6CENSUS: 0DATE:
05/23/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Yelena Aladadyan TIME COMPLETED:
11:15 AM
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Licensing Program Analyst (LPA) Joscelyn Martinez arrived at the facility to conduct an announced Pre-licensing inspection. This is a new licensee who will be operating a capacity of six (6) Residential Facility Care for the Elderly. The facility is a single story house and has three (3) bedrooms and three (3) bathrooms . The home has an attached living area that is not accessible to resident. Administrator Yelena Aladadyan will be living in this area of the home.

The physical plant was toured inside and out at 9:40 am.

Common Area: LPA observed the living room furniture to be clean and in good repair. LPA observed the dining area to be clean and in good repair. The facility maintains a comfortable temperature at 68 degrees F, which meet regulations. The air conditioner is operational. No firearms observed or will be maintained on the premises. Files, medication, PPE, and toiletries will be kept confidentially stored in a locked closet located in the hallway.

Resident rooms: All three (3) bedrooms will be shared. LPA observed rooms to have bedding sheets, pillowcase, blankets, which are in good condition. There is at least one chair, a night stand, and sufficient lighting for each resident. The mattresses and bedsprings were also checked for condition. Trash cans were observed having tight fitting lids. Window screens and window blinds are in good repair.

Bathrooms:All three (3) bathrooms were toured and checked to make sure bathrooms were clean and in good repair. The hot water temperature measured within regulations at 110.1 degrees F. The showers have non-slip bath mats and grab bars. Trash cans with lids were in the restroom to protect consumers from cross contamination. Towels and washcloths will not be shared.

Continue on 809-C

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Joscelyn Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 05/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/23/2022
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: AMAZING SENIOR CARE ON LASSEN, INC.
FACILITY NUMBER: 197610255
VISIT DATE: 05/23/2022
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Kitchen Area: LPA inspected the kitchen equipment. The refrigerator was clean and in good operation. Dishes in good repair. Cleaning supplies will be kept locked inaccessible in the garage. Fire extinguisher was observed with a purchase date of 01/28/22. Knives and sharp objects will be kept centrally stored and locked in a cabinet located in the kitchen. Stove and refrigerator are clean and in good operation. LPA observed a startup supply of non-perishable and perishable foods. Fist aid kits will be stored in the kitchen and the second one in the medication cabinet.

Outside: LPA toured the outside area. LPA observed a covered shaded area for resident and appropriate outdoor furniture. The facility has no bodies of water on the premises.

Garage: The garage is attached to the facility but there is no accesses to the door from inside the home. It will be used for additional storage of food, chemicals and laundry area. LPA discussed preplacement, staffing, training, customer service, inspection authority, reporting requirements (mandated reporter), records, citations, criminal record clearance, civil penalties, labor law, activities, expectation is to follow all rules and regulations.

Component III Conducted. Pre-licensing Inspection tool review all eleven inspection domains, no deficiencies were observed.


This report will be sent to Centralized Application Bureau (CAB). You will be notified by the CAB Analyst when the license has been approved. You are not allowed to begin operating until you have been notified that your license has been approved by the CAB Analyst. Failure to comply could affect approval of your license. You are to inform your LPA once you receive your first resident.

Exit interview conducted. Report signed and delivered.

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Joscelyn Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 05/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2022
LIC809 (FAS) - (06/04)
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