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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610469
Report Date: 04/03/2024
Date Signed: 04/03/2024 12:12:05 PM

Document Has Been Signed on 04/03/2024 12:12 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.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:ALLURE CARE MANORFACILITY NUMBER:
197610469
ADMINISTRATOR:
ADMINISTRATOR/
DIRECTOR:
SARGSYANFACILITY TYPE:
740
ADDRESS:11075 ARLETA AVENUETELEPHONE:
(818) 427-3965
CITY:MISSION HILLSSTATE: CAZIP CODE:
91345
CAPACITY: 6CENSUS: 3DATE:
04/03/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
TIME VISIT/
INSPECTION BEGAN:
09:08 AM
MET WITH:Karine Sargsyan - Licensee RepresentativeTIME COMPLETED:
TIME VISIT/
INSPECTION COMPLETED:
12:15 PM
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Licensing Program Analyst (LPA) Gary Tan conducted an announced Pre Licensing visit to this facility and met with Licensee representative Karine Sargsyan. The applicant is "Allure Care Manor Inc". Fire Clearance dated 10/27/23 was received for six (6) non-ambulatory residents, one (1) of which maybe bedridden on Room #1.

Purpose of today’s visit is to inspect the facility to ensure that the facility is in compliance with the rules and regulations of California Code of Regulations, Title 22, Division 6.

Facility is a single storey home. Today's site visit consisted of LPA touring the physical plant at 9:22 AM inside and outside and observed the following:

The facility smoke alarm system is hard wired and interconnected. The fire extinguisher is located near the dining area and was observed to be fully charged and last bought on 04/03/24. The facility uses a dual Carbon Monoxide/Smoke alarm detectors all over the common areas of the facility. Alarms were tested and observed to be operational. Hot water was tested in the common bathroom and measured at 118.2°F. There is a functioning telephone on the premises. An emergency exit plan/sketch is posted on the hallway wall with other posting requirements. There are four (4) resident bedrooms, room #2 and room #3 are shared room and the rest are private rooms. Resident bedrooms were observed to be appropriately furnished. There is an additional bedroom for designated for staff use. The common areas (living room, kitchen, office and dining areas) were appropriately furnished and lighting was adequate. The living room has a comfortable furniture. Residents, staff records and medications are stored in a designated secured filing cabinet in the staff room. The first aid kit is readily available in the kitchen. There are four (4) bathrooms in the facility. The bathrooms have appropriate grab bars installed and non-skid mats. One (1) bathroom is designated for staff use.

(continued to LIC 809-C)
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE: DATE: 04/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/03/2024
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.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: ALLURE CARE MANOR
FACILITY NUMBER: 197610469
VISIT DATE: 04/03/2024
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(continued from LIC 809)

The kitchen knives and sharps are stored in a locked drawer in the staff room. Kitchen cleaning supplies are stored in a locked in a filing cabinet in the backyard. Laundry detergents and other cleaning supplies and other toxins are stored in a locked storage room adjacent to the garage. The laundry area is located at the backyard. Facility appears to be clean and in good repair. Appliances in the kitchen appeared to be functional. 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.

There is a screening station immediately upon entrance. Sign in sheet, hand sanitizer, gloves and masks will be available. Required poster are posted all over the facility. The facility had submitted a Mitigation and Infection plan.

There is a sitting area in the back and side yards for residents to conduct outdoor activities. The backyard is fenced. There is no body of water in the facility. There is a storage area beside the laundry The garage was empty during visit, applicant representative at the facility stated that they not have any plan of converting the garage into an office or living quarter at this time.

Component III was conducted with the licensee representative and her house manager, Astrik Kababjian.

Facility is in compliance with Title 22 Regulations at this time. 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 conducted and copy of this report issued
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE:

DATE: 04/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/03/2024
LIC809 (FAS) - (06/04)
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