197610356-3-29-2023-31-AS-MRUZ-CQDPEP-20230329111527

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610356
Report Date: 03/29/2023
Date Signed: 03/29/2023 11:16:05 AM

Document Has Been Signed on 03/29/2023 11:16 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:	BELOVED LIVING		FACILITY NUMBER:	197610356
ADMINISTRATOR:	YEGISHYAN, VREJ		FACILITY TYPE:	740
ADDRESS:	15842 ACRE ST		TELEPHONE:	(818) 726-2805
CITY:	NORTH HILLS	STATE: CA	ZIP CODE:	91343
CAPACITY: 6		CENSUS: 0	DATE:	03/29/2023
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Vrej Yegishyan		TIME COMPLETED:	11:20 AM

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 3/29/2023, Licensing Program Analysts (LPA) Melissa Ruiz conducted an announced Pre-Licensing visit to this facility and met with applicant Anush Badalyan and Administrator Vrej Yegishyan. This is a new application and a fire clearance dated 6/17/2022 was received for six (6) residents, of which five (5) could be non-ambulatory residents, and one (1) bedridden in Room #2. Facility has a hospice waiver for six (6) residents. The purpose of today’s visit is to inspect the facility to ensure that it maintains compliance under California Code of Regulations, Title 22, Division 6. Today’s site visit consisted of LPA touring the physical plant inside and outside and observed the following: The facility has dual carbon monoxide and smoke alarm system. There is a fire extinguisher, with a date of purchase of 6/3/2022. There is a functioning telephone on the premises. An emergency exit plan/sketch is posted along the hallway wall with other posting requirements. There are five resident bedrooms, four of which are for resident use. One additional bedroom is designated for staff and will be also used as an office. Resident bedrooms were observed to be appropriately furnished. The common areas (living room, kitchen and dining areas) were appropriately furnished, and lighting was adequate. The living room has a television and comfortable furniture. Resident and staff records are stored in a locked cabinet in the designated staff room. Medications are centrally stored in a locked kitchen pantry. The first aid kit is readily available. There are two bathrooms in the facility, bathrooms have non-skid mats and appropriate grab bars. Trash cans were observed to have closed tight fitting lids. (CONT. on LIC809-C)

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Melissa Ruiz
LICENSING EVALUATOR SIGNATURE:	DATE: 03/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2023

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: BELOVED LIVING	FACILITY NUMBER: 197610356
	VISIT DATE: 03/29/2023

NARRATIVE

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The kitchen knives are stored in a locked cabinet. The chemicals and cleaning supplies are stored in a locked cabinet in the laundry area. The necessary precautions have been made to the facility to safely house dementia residents such as auditory alarms on all doors and locked areas for centrally stored medications. Facility appears to be clean and in good repair. Appliances in the kitchen appeared to be functional.

There is a sitting area in the backyard that is shaded. The backyard is fenced. The garage is attached to the house but there is no access from inside the facility. There are no bodies of water on the property.

Component III was conducted with applicant.

This report will be forwarded to the Centralized Application Bureau (CAB). You will be notified by the CAB Analyst when your license has been approved. Exit interview was conducted with Licensee. A copy of this report was signed and delivered.

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Melissa Ruiz
LICENSING EVALUATOR SIGNATURE:	DATE: 03/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2023

LIC809 (FAS) - (06/04)

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