197610280-5-22-2024-31-AS-GSAO-D5HQL2-20240522121512

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610280
Report Date: 05/22/2024
Date Signed: 05/22/2024 12:15:46 PM

Document Has Been Signed on 05/22/2024 12:15 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 S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	A DREAM VILLA		FACILITY NUMBER:	197610280
ADMINISTRATOR/ DIRECTOR:	TER-ARSENYAN, AZNIV		FACILITY TYPE:	740
ADDRESS:	17304 PARTHENIA STREET		TELEPHONE:	(747) 256-2025
CITY:	SHERWOOD FOREST	STATE: CA	ZIP CODE:	91325
CAPACITY: 6		CENSUS: 6	DATE:	05/22/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	12:08 AM
MET WITH:	Azniv Ter-Arsenyan		TIME VISIT/ INSPECTION COMPLETED:	12:20 PM

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25

On 05/22/2024 at 08:55 AM, Licensing Program Analyst (LPA) Gina Saucedo conducted an unannounced, Annual Inspection and met with caregiver, Gayane Grigoryanya and the administrator Azniv Ter-Arsenyan was called and arrived about fifteen (15) minutes later.

The physical plant was toured inside and out at 9:20 am.

Living/Dining Room Area: LPA Saucedo observed the living room furniture to be clean and in good repair. The facility maintains a comfortable temperature at 70 degrees Fahrenheit. There is a fire extinguisher at the entrance of the facility on your left-hand side dated 06/2023. The telephone line located in the living room.

Bedrooms: All six (6) bedrooms are single, occupied. All resident rooms are numbered. LPA observed rooms to have bedding sheets, pillowcase, blankets, nightstands, televisions, and sufficient lighting for each of the residents sharing the room. Next to bedroom number one (1) there is a closet that is filled with extra linen. There is also a staff office only accessible to staff.

Bathrooms: There are two (2) bathrooms that were toured and checked to make sure bathrooms were clean and in good repair. The hot water temperature measured within regulations of 115 degrees Fahrenheit and 118. The showers have non-slip bathmats and grab bars.

Medications were kept in a locked cabinet in the hallway. All medications were properly labeled and inaccessible to residents.

Kitchen Area: LPA inspected the kitchen area. The refrigerator was clean and in good operation. Knives and sharp objects were kept centrally stored and locked in a cabinet located in the kitchen on your right-hand side. LPA observed sufficient supply of seven (7) day non-perishable and perishable foods in the cabinet. There is a complete first aid kit located in the kitchen.

LIC 809C-continued

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Gina Saucedo
LICENSING EVALUATOR SIGNATURE:	DATE: 05/22/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2024

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 S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: A DREAM VILLA	FACILITY NUMBER: 197610280
	VISIT DATE: 05/22/2024

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Outside: LPA toured the outside area. LPA observed a covered shaded area for residents and appropriate outdoor furniture. The facility has no body of water on the premises. There is one gate that is locked leading to the outside area towards the street. There are also ramps provided for wheelchair residents. There is one (1) shed that LPA was able to observe and there is a bird cage that is locked and inaccessible to the residents.

The carbon monoxide is interconnected with the smoke detector was tested and it was operable. There is also a signal system for the above facility.

Garage: The garage is attached to the facility there is an access door from the laundry area. It is used for additional storage of food, chemicals, and laundry area. The laundry area has one (1) washer and one (1) dryer. There are chemicals and extra hygiene on the top shelves inaccessible to the residents.

Administration: The mitigation and the Infection control were reviewed and there was Covid 19 signs on the wall, hygiene sanitation signs, Ombudsman, Theft and Loss Policies, Emergency and Disaster Plan,Rights of Resident Council, Personal Rights and YES sign, surety bond was viewed, and it is up to date.

The carbon monoxide is interconnected with the smoke detector was tested and it was operable.

An exit interview was conducted, no citations were issued, and a copy of this report was given to the administrator.

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Gina Saucedo
LICENSING EVALUATOR SIGNATURE:	DATE: 05/22/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2024

LIC809 (FAS) - (06/04)

Page: 2 of 2