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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610490
Report Date: 12/13/2023
Date Signed: 12/13/2023 11:47:23 AM

Document Has Been Signed on 12/13/2023 11:47 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:ARCHWOOD ASSISTED LIVINGFACILITY NUMBER:
197610490
ADMINISTRATOR:DISHOYAN, ARMINEFACILITY TYPE:
740
ADDRESS:17981 ARCHWOOD STREETTELEPHONE:
(747) 788-0208
CITY:RESEDASTATE: CAZIP CODE:
91335
CAPACITY: 6CENSUS: 0DATE:
12/13/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:Alina Solloway, Armine DishoyanTIME COMPLETED:
11:45 AM
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Licensing Program Analyst (LPA) Michael Cava conducted a Pre-Licensing Inspection with the applicant representative and administrator, Alina Solloway and Armine Dishoyan. An Application to operate a Residential Care Facility for the Elderly (RCFE) was received by Community Care Licensing (CCL) on August 31, 2023. A fire clearance was approved on October 19, 2023 for six (6) non-ambulatory residents of which one (1) may be bedridden, for a total capacity of six. The applicant is also requesting a hospice waiver to retain four (4) residents. The smoke alarms and carbon monoxide detector are dueal and hard wired. The facility has one new fire extinguisher that was purchased on October 19, 2023, that is located in dining room/kitchen area.

A tour of the physical plant was initiated at approximately 9:45am and the following was observed:

KITCHEN: The facility has a Kitchen area that is equipped with a refrigerator, microwave oven and sink. There were adequate supplies nonperishable food and dining ware to accommodate a maximum capacity of six (6). Knives were observed locked in a kitchen drawer.

BEDROOMS: There are four (4) bedrooms designated for client use. Per STD 850, Bedroom #1 and #3 are shared rooms but cleared for only one bedridden at any time. Bedroom #2 is cleared for non-ambulatory. Bedroom #4 is cleared for ambulatory only. The applicant furnished the resident bedrooms with beds, night stand, chairs, dresser, bedding and linen. The bedrooms have sufficient lighting and closet space.

BATHROOMS: The facility has three (3) bathrooms. The bathrooms were observed to have the proper fixtures, grab bars, and non-skid mats. The hot water delivered in the bathrooms measured at 105 degrees.
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Michael Cava
LICENSING EVALUATOR SIGNATURE: DATE: 12/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/13/2023
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: ARCHWOOD ASSISTED LIVING
FACILITY NUMBER: 197610490
VISIT DATE: 12/13/2023
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COMMON AREAS: These included the living room which was equipped with a couch, chair, a television and two tables. The dining area has a large dining room table to accommodate six (6). There were no visible immediate hazards.

LAUNDRY ROOM: The laundry room is located in the hallway by room #1. The washer/dryer are brand new. Detergents and cleaning supplies will be kept in another locked closet.

MEDICATIONS: The medication closet is located in the same hallway as the laundry room and room #1. It was observed locked will be maintained inaccessible to the residents at all times. A complete first aid kit and manual stored in the medication closet

OFFICE/STAFF WORKSTATION: For the time being, although Room #4 is cleared for ambulatory only, it will be temporary used for staff office until needed to accept a resident that is ambulatory only, not to exceed the fire-clearance for a capacity of six (6).

SURROUNDING GROUNDS: The driveway, passageways and entrance to the home was clear of obstruction. All entry and exit doors have a functional auditory alert when the doors open. The backyard of the facility has a patio and backyard furniture to accommodate the six (6) residents. The facility backyard has sufficient yard space. No pools or bodies of water observed in the front or back yards.

In addition to the Pre-Licensing inspection, a Component III power point presentation was held between 9:10am to 9:45am.

Pursuant to Title 22, Division 6 of the CA Code of Regulations, the facility's physical environment appears to be compliant and ready for licensure. CAB will be advised and a copy of this report provided.

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Michael Cava
LICENSING EVALUATOR SIGNATURE:

DATE: 12/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/13/2023
LIC809 (FAS) - (06/04)
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