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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610474
Report Date: 03/06/2024
Date Signed: 03/06/2024 10:48:11 AM

Document Has Been Signed on 03/06/2024 10:48 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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:LINDLEY RESIDENTIAL CAREFACILITY NUMBER:
197610474
ADMINISTRATOR:AVETISYAN, ARMENUHIFACILITY TYPE:
740
ADDRESS:18126 W VINTAGE STREETTELEPHONE:
(818) 983-2224
CITY:NORTHRIDGESTATE: CAZIP CODE:
91325
CAPACITY: 6CENSUS: DATE:
03/06/2024
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
08:25 AM
MET WITH:Armenuhi AvetisyanTIME COMPLETED:
10:55 AM
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On 03/06/24, at 8:25am, Licensing Program Analyst (LPA), Gina Saucedo, conducted an announced visit to the facility for purpose of a pre-licensing evaluation.

An application was submitted to Community Care Licensing Division-CCLD on 08/07/2023, Initial license for a Residential Care Facility for the Elderly, 60 years and older. The requested capacity is for five (5) non-ambulatory and one (1) bedridden, total of up to six (6) residents but fire clearance does state all bedrooms are cleared for bedridden as long as it is one (1) at a time.

Facility is a single-story home. Today's site visit consisted of LPA touring the physical plant at 8:45 AM inside and outside and observed the following:

Bedrooms Staff:

There is no bedroom designated for staff at this time.

Bedrooms Residents:
There is a total of six (6) bedrooms for resident use. There shall be no more than two clients per bedroom if used for non-ambulatory. All bedrooms are cleared for bedridden but only one (1) at a time. Two (2) of the bedrooms have private bathrooms. The other two (2) full bathrooms have proper grab bars and non-skid mats. The other half bathrooms also have grab bars. All the bedrooms have proper bedding, chairs, nightstands, lamps in addition to overhead lighting.

LIC 809C-continued
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Gina Saucedo
LICENSING EVALUATOR SIGNATURE: DATE: 03/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/06/2024
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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: LINDLEY RESIDENTIAL CARE
FACILITY NUMBER: 197610474
VISIT DATE: 03/06/2024
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The dining/living room Resident & Staff Files:
There is enough seating for staff and residents. The furniture is in good condition. The resident/staff files will be kept in a black cabinet next to the living room/dining room area on your right-hand side.

Linens & Hygiene Supplies:
Adequate supply of linen stored in the cabinets next to the bedrooms in the hallway.

Emergency Phone Numbers, Exit Plan & Menu:


The facility has a working phone number land line. Fire Extinguisher located near kitchen door on your right-hand side mounted on the wall. It is fully charged and has a date of July 2024. There is another fire extinguisher in the living room/dining room area by the entrance of the facility.

Food Service:
Dishes, cups, and flat ware are stored in the kitchen cupboards, inspected and in good repair. Sharps are stored on your right-side of the kitchen locked and secured in a lock box inaccessible to the residents. Food supply adequate stored in several cabinets and consists of the following: canned goods, bottles of water. The refrigerator, stove and microwave are in good condition and working.

Smoke Detectors:
There are smoke detectors/carbon monoxide through-out the house that were tested and work properly. They are hardwired and interconnected.

Water Temperature:
The water temperature was tested for the bathrooms are they are within regulation:116.-118 Fahrenheit.

Pool/Jacuzzi:
There is no pool/jacuzzi in the facility.

LIC 809C-continued
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Gina Saucedo
LICENSING EVALUATOR SIGNATURE:

DATE: 03/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/06/2024
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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: LINDLEY RESIDENTIAL CARE
FACILITY NUMBER: 197610474
VISIT DATE: 03/06/2024
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Fire clearance:
Fire Clearance was approved on 02/07/2024 signed and dated.

Signal system:


The facility does have a signal system installed.

Administration:
The facility had submitted a Emergency and Disaster Plan For Residential Care Facilities For The Elderly and Infection plan. There is billboard on your left-hand side of the facility with Personal Rights of Residents, Rights of Resident by Council, Infection Control, Disaster Plan, Facility Sketch and Theft and Loss Policy. The Component III was shown to the Administrator although they have previously seen it/orientation process was completed.

Structure:
Overall Facility is a six (6) bedroom home with four (4) full-bathrooms and two (2) bathrooms with no shower, single-story. The home does not have a fireplace. There is one (1) washer and dryer located next to hallway which is locked and inaccessible to the residents. There is three (3) pantry areas for extra linen and other storage that are also locked and inaccessible to the residents.

Pre-licensing:
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 to the administrator.
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Gina Saucedo
LICENSING EVALUATOR SIGNATURE:

DATE: 03/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

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