197610517-7-16-2024-31-AS-AAEA-D78SJX-20240716135553

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610517
Report Date: 07/16/2024
Date Signed: 07/16/2024 01:56:06 PM

Document Has Been Signed on 07/16/2024 01:56 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.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	FUTURE SENIOR LIVING 1		FACILITY NUMBER:	197610517
ADMINISTRATOR/ DIRECTOR:	BERBERYAN, NELLI		FACILITY TYPE:	740
ADDRESS:	17401 TROSA STREET		TELEPHONE:	(323) 383-7738
CITY:	GRANADA HILLS	STATE: CA	ZIP CODE:	91344
CAPACITY: 6		CENSUS: 0	DATE:	07/16/2024
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:45 AM
MET WITH:	Administrator, Nelli Berberyan		TIME VISIT/ INSPECTION COMPLETED:	02:10 PM

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25

At 10:00AM Licensing Program Analyst (LPA), Antonia Alvizar-Ettima conducted an announced Pre-Licensing visit to the above facility and met with Administrator, Nelli Berberyan. An Application to operate a Residential Care Facility for the Elderly (RCFE) was received by Community Care Licensing (CCL).

Fire Clearance was approved on 06/21/2024 for a maximum capacity of six (6) non-ambulatory residents, of which one (1) may be bedridden in bedroom #5. Waiver/Granted for hospice care for six (6) residents. The purpose of today’s visit is to inspect the facility to ensure that the physical plant is in compliance with rules and regulations of California Code of Regulations, Title 22, Division 6, Chapter 8. The facility is a single-story building in a residential community. The facility has one new fire extinguishers that was purchased on April 15, 2024. The fire extinguisher is located at the enters of the facility.

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

KITCHEN: The facility has a kitchen area that is equipped with a refrigerator, sink and stove. There were adequate supplies of perishable and nonperishable food and dining ware to accommodate a maximum capacity of six (6) residents. All knives and sharps are observed to be locked in a cabinet in the kitchen and inaccessible to residents.

LAUNDRY ROOM: The laundry room is located outside the home. The washer/dryer appear to be in good condition. Laundry supplies are kept inaccessible when not in use in a locked cabinet in the home.

BEDROOMS: There are five (5) bedrooms designated for residents to use. Bedroom #5 is a shared room, bedrooms #1 - #4 are private rooms. All resident bedrooms are furnished with bed, chair, nightstand, dresser and required bedding and linen. The bedrooms have sufficient closet space and have sufficient lighting. Auditory alarms were tested and observed to be operational.

Continue on LIC809-C

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Antonia Alvizar-Ettima
LICENSING EVALUATOR SIGNATURE:	DATE: 07/16/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2024

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.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: FUTURE SENIOR LIVING 1	FACILITY NUMBER: 197610517
	VISIT DATE: 07/16/2024

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

BATHROOMS: LPA inspected the bathrooms they are clean and in excellent condition located in the hallway. LPA observed two (2) bathrooms with grab bar and non-skid mats for residents and staff to use. Water temperature was within regulation ranging between 115.9°F – 116.4°F. LPA also observed sufficient quantity of toilet papers, soap and paper towels.

COMMON AREAS: The facility maintains a comfortable temperature at 74°F. The living room has a couches, television and an ottoman with color books, crayons, markers, poker cards and puzzles. The dining area has a table and chairs that were clean and properly furnished.

MEDICATION: The medication will be kept in a cabinet in the living room area. All medication will be locked inaccessible to residents. The facility staff/resident files will be kept in a locked cabinet in dining room area and inaccessible to residents.

SMOKE DETECTORS/CARBON MONOXIDE.

Eight (8) smoke detectors were located in the bedrooms and throughout the facility. Seven (7) out eight (8) smoke deters were dual carbon monoxide detectors and inter-connected. They were tested and observed to be operational.

SURROUNDING GROUNDS: The entrance to the home is gated. The 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 right side of the facility has no access to the residents. There is an approved Accessory Dwelling Unit (ADU) on the right side of the facility, that has it's own private entrance, leaving no accessibility to the residents. The exterior left side and backyard of the facility is for resident use only and has sufficient yard space. LPA observed appropriate outdoor furniture, fruit trees with a covered shaded area for residents. LPA discussed the importance of maintaining the care and supervision to meet the needs of residents. There are no bodies of water.

Component III: Upon review of the Licensing records, LPA noted that on 04/17/2024 the applicant representative/Licensee Nelli Berberyan completed the Component III during Pre-Licensing visit at facility “Future Senior Living #197610519” at which time the applicant was explained how to operate the facility within substantial compliance and had an opportunity to ask questions therefore, Component III was waived.

Based on inspection and observation, the physical plant is in compliance with Title 22 Regulations at this time. This report will be forwarded to the Centralized Application Bureau (CAB) and the applicant will 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 Administrator.

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Antonia Alvizar-Ettima
LICENSING EVALUATOR SIGNATURE:	DATE: 07/16/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2024

LIC809 (FAS) - (06/04)

Page: 2 of 2