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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610489
Report Date: 12/05/2023
Date Signed: 12/05/2023 11:45:25 AM

Document Has Been Signed on 12/05/2023 11:45 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:VELVET CARE 2FACILITY NUMBER:
197610489
ADMINISTRATOR:PAROYAN, NAIRAFACILITY TYPE:
740
ADDRESS:16909 CITRONIA STREETTELEPHONE:
(310) 480-2009
CITY:NORTH HILLSSTATE: CAZIP CODE:
91343
CAPACITY: 6CENSUS: 0DATE:
12/05/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Naira Papoyan, Administrator TIME COMPLETED:
11:10 PM
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At 10:00am Licensing Program Analyst (LPA), Angela Panushkina conducted an announced Pre-Licensing visit to the above facility and met with Applicant/Licensee, Hayk Kirakosyan and Administrator, Naira Paroyan.

Fire Clearance was approved on 10/26/2023 for a maximum capacity of six (6) residents, of which five (5) Non-Ambulatory and one (1) bedridden residents in room #3. Hospice waiver for six (6) residents was approved on 12/05/23.

The purpose of today’s visit is to inspect the facility to ensure that the facility is in compliance with rules and regulations under California Code of Regulations, Title 22, Division 6. The facility is a single-story building. Today's site visit consisted of LPA touring the physical plant inside and outside and observed the following:

KITCHEN: The facility has a Kitchen that is equipped with a refrigerator, microwave oven and sink. At 10:10am, LPAs observed adequate supplies of perishable and nonperishable food and dining ware to accommodate a maximum capacity of six (6). All knives and sharps are observed to be locked in a kitchen drawer and inaccessible to residents. Fire Extinguisher was last purchased on 12/05/23.


BEDROOMS: There are four (4) bedrooms designated for client use. All bedrooms are furnished with beds, dressers and required bedding and linen. The bedrooms have sufficient closet space and have sufficient lighting. Auditory alarms were tested and observed to be operational.

BATHROOMS: At 10:25am LPA observed two (2) bathrooms are clean and in good repair. Properly supplied with toilet papers, soap and paper towels. The hot water temperature measured at 112.5°F. LPA observed appropriate grab bar and had non-skid mat. Continue on LIC809-C
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Angela Panushkina
LICENSING EVALUATOR SIGNATURE: DATE: 12/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/05/2023
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: VELVET CARE 2
FACILITY NUMBER: 197610489
VISIT DATE: 12/05/2023
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COMMON AREAS: The facility maintains a comfortable temperature at 75°F. The living room and dining appeared clean and were properly furnished. No obstructions and or tripping hazards throughout the facility.

LAUNDRY ROOM: The laundry room is located by the kitchen area. The washer/dryer appear to be in good condition. Laundry supplies are kept inaccessible when not in use with supervision.

MEDICATION: The medication will be kept in a locked cabinet also located in the laundry room. The facility staff/resident files will be kept in a file cabinet in the living room area.

SMOKE DETECTORS/CARBON MONOXIDE. Smoke detectors and carbon monoxide were located throughout the facility. At 10:50am they were tested and observed to be operational.


SURROUNDING GROUNDS: In the back of the facility has sufficient yard space. LPA observed appropriate outdoor furniture, with a covered shaded area for clients. The backyard is fenced. LPA discussed the importance of maintaining the care and supervision to meet the needs of clients. There are no bodies of water

GARAGE: The garage is detached and currently being used for storage. LPA observe the garage locked and inaccessible to residents in care.

Component III was conducted with the Administrator.

Facility is in compliance with Title 22 Regulations at this time. This report will be forwarded to the Centralized Application Bureau (CAB) and be notified by the CAB Analyst when your license has been approved.

Exit interview was conducted and with a copy of this report was provided to the Applicant/Administrator.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Angela Panushkina
LICENSING EVALUATOR SIGNATURE:

DATE: 12/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2023
LIC809 (FAS) - (06/04)
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