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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610509
Report Date: 02/04/2025
Date Signed: 02/04/2025 02:27:23 PM

Document Has Been Signed on 02/04/2025 02:27 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:KK SUNNYBRAE SENIOR LIVINGFACILITY NUMBER:
197610509
ADMINISTRATOR/
DIRECTOR:		PODRUMYAN, MAROFACILITY TYPE:
740
ADDRESS:10012 SUNNYBRAE AVETELEPHONE:
(818) 632-2742
CITY:CHATSWORTHSTATE: CAZIP CODE:
91311
CAPACITY: 6CENSUS: 3DATE:
02/04/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Karine Karapetyan, Administrator TIME VISIT/
INSPECTION COMPLETED:
03:00 PM
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At 09:30am Licensing Program Analyst (LPA), Angela Panushkina conducted an announced annual visit to the above facility. LPA met with Administrator, Karine Karapetyan, and explained the reason for the visit.

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 team touring the physical plant inside and outside and observed the following:

The facility currently has three (3) residents, one (1) of which is bedridden/hospice in room #4.

At 10:20am, LPA toured the kitchen area and observed adequate supplies of two (2)-days perishable and one (1) week nonperishable food. All knives and sharps are locked in the kitchen drawer and inaccessible to residents. Additionally, LPA observed all medications are kept in the locked kitchen cabinet. LPA inspected the First Aid Kit and observed all required equipment’s are available. Fire extinguisher was placed by the kitchen/dining areas and was observed fully services.

At 10:30am, LPA visited four (4) resident bedrooms and observed all rooms appropriately furnished with sufficient closet space and lighting. Two (2) out of four (4) rooms have exit/sliding doors and LPA observed auditory alarms operational. LPA was informed that the facility currently has two (2) dementia residents and awake staff. The facility has two and a half (2½) bathrooms in good repair and properly supplied with toilet papers, soap and paper towels. Appropriate grab bars and non-skid mats were also observed. At 10:45am, the hot water temperature measured at 110°F. The facility maintains a comfortable temperature at 78°F. The living room and dining appeared clean and were properly furnished. No obstructions and or tripping hazards throughout the facility.
Continue on LIC809-C
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Angela Panushkina
LICENSING EVALUATOR SIGNATURE: DATE: 02/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/04/2025
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: KK SUNNYBRAE SENIOR LIVING
FACILITY NUMBER: 197610509
VISIT DATE: 02/04/2025
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The fireplace located in the dining room is adequately closed and inaccessible to residents in care. The laundry is located in an attached garage and LPA observed washer/dryer in a good condition. All laundry supplies are kept locked and inaccessible to residents in care. Smoke detectors and carbon monoxide were located throughout the facility. At 11:00am they were tested and observed to be operational. At 11:10am, LPA toured the backyard and observed the facility has sufficient space and appropriate outdoor furniture, with a covered shaded area for residents. There are no bodies of water, and the backyard is fenced all around. Between 11:30am to 1:30pm, LPA reviewed records of three (3) residents and three (3) staff. Resident and staff records appeared to be complete and updated.

LPA collected Certificate of Liability Insurance and LIC500.

No deficiency cited during today's visit.
Exit interview conducted and copy of this report signed and delivered.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Angela Panushkina
LICENSING EVALUATOR SIGNATURE:

DATE: 02/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/04/2025
LIC809 (FAS) - (06/04)
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