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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610293
Report Date: 12/08/2022
Date Signed: 12/08/2022 11:42:34 AM

Document Has Been Signed on 12/08/2022 11:42 AM - 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:SUNRISE AT LINDLEY IFACILITY NUMBER:
197610293
ADMINISTRATOR:MELIKSETYAN, LUSINEFACILITY TYPE:
740
ADDRESS:9955 LINDLEY AVETELEPHONE:
(747) 218-9141
CITY:NORTHRIDGESTATE: CAZIP CODE:
91325
CAPACITY: 6CENSUS: 0DATE:
12/08/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Lusine MeliksetyanTIME COMPLETED:
11:55 AM
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On 12/08/22 Licensing Program Analyst (LPA) Joscelyn Martinez arrived at the facility to conduct a Pre-licensing investigation. Upon arrival LPA met with Administrator Lusine Meliksetyan and the purpose of the visit was explained. This is an application is for Residential Care Facility for Elderly. Facility has requested a total capacity of six residents (6) of which five (5) may be non-ambulatory and one (1) bedridden. This is a single-story home with six (6) bedrooms and six (6) bathrooms. All bedrooms have been cleared for bedridden residents, but facility may only have one bedridden resident at a time.

Common Area: LPA observed the living room and 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 of 70 degrees F, which meet regulations. The air conditioner is operational. No firearms observed or will be maintained on the premises. Facility contains dual smoke alarm and carbon monoxide detector. Detectors were operational and tested at 10:50 a.m. The fire extinguisher was observed to be full with a service date of 07/11/22. Facility maintains a telephone landline that was tested and observed to be operational. Activities were observed in the living room area. Medications and files will be kept in a locked cabinet in the living area. First aid kit was observed and contained the proper items stated by regulations. Laundry area was observed in the hallway closet. No chemicals will be stored inside this closet.

Kitchen Area: LPA observed the kitchen area to be in good repair and sanitary. LPA observed a start up supply of food as well as emergency food. Sharps were observed to be locked and inaccessible to residents. Trash can contain a tight-fitting lid. Chemicals are locked and stored under the kitchen sink. LPA observed plates and cups for resident’s use.

Bedrooms: Facility has six (6) bedrooms all designated for private residents use. All bedrooms were toured and were observed with the appropriate furniture and bedding. LPA observed sufficient linens for resident’s use.

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Joscelyn Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 12/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/08/2022
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: SUNRISE AT LINDLEY I
FACILITY NUMBER: 197610293
VISIT DATE: 12/08/2022
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Bathrooms: Facility has six (6) bathrooms. Bathrooms were toured and were observed to have trash cans with tight fitting lids. The showers contained grab bars and non-skid mats. Hot water was tested and measured at 118.2 degrees F. LPA observed enough towels and wash cloths for residents.

Outside: LPA observed appropriate outdoor furniture with a shaded area for residents. Facility is gated and has an additional two homes on the properties. Administrator stated these home will be used as an RCFE in the future. There are no bodies of water on the property.

Pre-Licensing Self-Certification checklist was discussed with administrator. 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. No deficiencies were observed.

Once component III is completed, 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.

Report signed and delivered.

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

DATE: 12/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/08/2022
LIC809 (FAS) - (06/04)
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