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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610407
Report Date: 04/24/2023
Date Signed: 04/24/2023 01:16:38 PM

Document Has Been Signed on 04/24/2023 01:16 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:PURE ASSISTED LIVINGFACILITY NUMBER:
197610407
ADMINISTRATOR:GHAZARYAN, NARINEFACILITY TYPE:
740
ADDRESS:9550 REMICK AVETELEPHONE:
(818) 809-8559
CITY:PACOIMASTATE: CAZIP CODE:
91331
CAPACITY: 6CENSUS: 0DATE:
04/24/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Seda Smbatyan, LicenseeTIME COMPLETED:
01:40 PM
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Licensing Program Analyst (LPA) Shira Stamps met with Seda Smbatyan (Licensee/Applicant) and Narine Ghazaryan (Administrator) for a Pre-licensing inspection at 10:30 am.

Entrance interview conducted.

The facility has four (4) bedrooms and two (2) bathrooms designated for a capacity of six (6) six. One (1) bedroom is designated for bedridden. Staff will be awake at night. The physical plant was toured inside and out at 10:40 am.

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 at 69 degrees F, which meet regulations. The air conditioner is operational. No firearms observed or will be maintained on the premises.

The smoke alarm and carbon monoxide detector were operational and tested at 11:00 am. The fire extinguisher appears to be full.

Resident rooms: LPA observed rooms to have bedding sheets, pillowcase, blankets, which are in good condition. There is at least one chair, a nightstand, and sufficient lighting for each client. The mattress and bedspring were also checked for condition.

Window covering and window screens are in good repair for each room.

Residents will have sufficient amounts of supplies for personal hygiene products, which is provided by the Licensee.

Continued...

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Shira Stamps
LICENSING EVALUATOR SIGNATURE: DATE: 04/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/24/2023
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: PURE ASSISTED LIVING
FACILITY NUMBER: 197610407
VISIT DATE: 04/24/2023
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Bathrooms: LPA toured resident bathrooms and checked to make sure bathrooms were clean and in good repair. The hot water temperature measured within regulations at 115.4 degrees F. Each shower contained non-skid mats and trash cans with lids in the restroom to protect consumers from cross contamination. Towels and washcloths will not be shared.

Kitchen Area: LPA inspected kitchen equipment. The refrigerator was clean and in good operation. Dishes in good repair. Knives and cleaning supplies will be kept locked inaccessible in the kitchen and laundry room.

Medications will be kept centrally stored and locked in a cabinet. Stove clean and in good operation. LPA observed start uo supply of non-perishable foods.

Outside: LPA toured the outside area. LPA observed a covered shaded area for residents. The laundry room is located outside and will remain locked at all times. There are two sheds that will remain locked. No bodies of water on the premise.

Garage: There is no garage.

Files will be kept confidentially stored in a locked cabinet located in the kitchen and supplied to licensing staff upon request.

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.

Applicant/ Administrator has completed component III. Exit interview conducted and report delivered to Licensee/Applicant.

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Shira Stamps
LICENSING EVALUATOR SIGNATURE:

DATE: 04/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2023
LIC809 (FAS) - (06/04)
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