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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610563
Report Date: 03/20/2025
Date Signed: 03/20/2025 03:24:33 PM

Document Has Been Signed on 03/20/2025 03:24 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:A-1 ASCENDED SENIOR CARE 3FACILITY NUMBER:
197610563
ADMINISTRATOR/
DIRECTOR:		AIDA MANUKYANFACILITY TYPE:
740
ADDRESS:20022 VINTAGE STREETTELEPHONE:
(818) 268-6707
CITY:CHATSWORTHSTATE: CAZIP CODE:
91311
CAPACITY: 6CENSUS: 3DATE:
03/20/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:40 PM
MET WITH:Aida Manukyan, Administrator TIME VISIT/
INSPECTION COMPLETED:
03:45 PM
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At 12:40pm, Licensing Program Analysts (LPAs) Angela Panushkina arrived at the facility to conduct an unannounced annual inspection. Upon arrival, LPA met with the Administrator and explained the reason for the visit.

At 12:45pm LPA conducted a tour of the physical plant and observed the following:

Facility is approved for six (6) Non-ambulatory, of which six (6) may be Bedridden. Facility also has a hospice waiver granted for six (6) residents.

There are six (6) bedrooms designated for residents’ use. Facility maintains a comfortable temperature of 77°F. LPA observed there to be sufficient stock of one-week perishable foods and two-day non-perishable foods. Frozen foods are properly wrapped and stored appropriately. Food storage and preparation areas are clean and inaccessible to pests. All knives were observed to be locked in the kitchen drawer. The fire extinguisher is located in the hallway by the kitchen area and was last serviced on 02/19/2025. Medications are stored in a locked cabinet, located in the hallway. There is a complete first-aid kit in the cabinet with all required supplies and with the first aid manual. Bedrooms are appropriately furnished and have appropriate lighting. Bathrooms have soap, paper towels and all trash cans have a lid. Extra towels and linens were readily available. The hot water temperature measured at 115.5°F. Laundry is located in the garage. The washer/dryer appear to be in good condition. Laundry supplies, chemicals and detergents are kept in the garage and inaccessible to residents in care. Smoke detectors and carbon monoxide monitors were tested at 2:00pm and observed to be functional. At 2:05pm, LPA observed appropriate outdoor furniture, with a covered shaded area for residents. LPA also observed sufficient yard space with fenced backyard. The outdoor area was free of visible immediate hazards. LPA discussed the importance of maintaining the care and supervision to meet the needs of residents.
Continue on LIC809-C

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Angela Panushkina
LICENSING EVALUATOR SIGNATURE: DATE: 03/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/20/2025
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: A-1 ASCENDED SENIOR CARE 3
FACILITY NUMBER: 197610563
VISIT DATE: 03/20/2025
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Between 2:10pm to 2:30pm, LPA reviewed records of three (3) residents and one (1) staff. Resident and staff records appeared to be complete and updated. Resident’s files contain signed admission agreements and a medical assessment, and all other required documentarians.

LPAs collected Certificate of Liability Insurance, Administrator Certificate and LIC500.

No citations issued during this 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: 03/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2025
LIC809 (FAS) - (06/04)
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