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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610585
Report Date: 08/23/2024
Date Signed: 08/23/2024 12:01:05 PM

Document Has Been Signed on 08/23/2024 12:01 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:CHATSWORTH ASSISTED LIVINGFACILITY NUMBER:
197610585
ADMINISTRATOR/
DIRECTOR:		DANIELYAN, GEORGIYFACILITY TYPE:
740
ADDRESS:20210 TUBA STREETTELEPHONE:
(818) 421-5272
CITY:CHATSWORTHSTATE: CAZIP CODE:
91311
CAPACITY: 6CENSUS: 0DATE:
08/23/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Georgiy Danielyan, Administrator TIME VISIT/
INSPECTION COMPLETED:
12:30 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 facility Licensee/Administrator, Georgiy Danielyan.

Fire Clearance was approved on 03/29/24 for a maximum capacity of six (6) residents, of which five (5) can be Non-ambulatory and one (1) Bedridden resident. Bedridden is cleared for bedrooms #1, #2 and #3. Facility has Dementia Care Program. 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. 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 area that is equipped with a new refrigerator, microwave oven and sink.
At 10:15am, LPA observed adequate supplies of nonperishable food properly stored in the cabinets and inside the supply room. Perishable food items are not required at this time as there are no residents in the facility. Licensee will supply sufficient amount of perishable food upon arrival of the residents. LPA observed 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 in care. The facility has one (1) new fire extinguisher, appeared to be full and serviced and were last purchased on 01/11/24.

BEDROOMS: There are five (5) bedrooms designated for residents use. All bedrooms are furnished
with beds, dressers, chairs, night stands and required bedding and linen. The bedrooms have sufficient closet space and have sufficient lighting. Auditory alarms were tested and observed to be operational at 10:30am. Facility has an office/room for staff, but due to dementia resident will have awake staff at night. Emergency call buttons are available and will be provided to residents.
Continue on LIC809C
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Angela Panushkina
LICENSING EVALUATOR SIGNATURE: DATE: 08/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/23/2024
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 3
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: CHATSWORTH ASSISTED LIVING
FACILITY NUMBER: 197610585
VISIT DATE: 08/23/2024
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BATHROOMS: Facility has three (3) bathrooms. At 10:45am LPA observed all bathrooms are clean, in good repair and properly supplied with toilet papers, soap and paper towels. LPA observed appropriate grab bars and non-skid mats in all bathrooms. Trash cans had closed tight fitting lids throughout. At 10:45am, a water temperature was measured between 109.3-109.7°F. Bathrooms #4 by the garage is designated for staff use only.

MEDICATION ROOM: The medication will be centrally stored in the hallway cabinet, by the room #3 and will be kept locked and inaccessible to residents in care. Facility staff/resident files will be kept centrally stored and locked in the cabinet located in the office. First-aid kit was checked to be complete and has the new manual available.

COMMON AREAS: The facility maintains a comfortable temperature at 72°F. The living room and dining area appeared clean and were properly furnished. The facility has separate activity room were puzzles, coloring books, crayons, board games and other activity supplies are available. No obstructions and or tripping hazards throughout the facility. An emergency exit plan/sketch is posted along the hallway with other posting requirements.

LAUNDRY ROOM: The laundry room is located in the garage, which is locked all the time. The washer/dryer appear to be new and in good condition. Laundry supplies along with other chemical items are kept locked inaccessible under supervision when not in use.

SMOKE DETECTORS/CARBON MONOXIDE. Dual smoke detectors and carbon monoxide were located in
the bedrooms and throughout the facility. At 11:00am they were tested and observed to be operational.

SURROUNDING GROUNDS: The facility has gated entrance and sufficient yard space. LPA observed appropriate outdoor furniture, with a covered shaded area for residents. The backyard is fenced. There is an attached garage which is currently being used for storage/break room/laundry. LPA discussed the importance of maintaining the care and supervision to meet the needs of the residents. The property has properly fenced and locked pool, which is inaccessible to residents. The facility has land line located in the hallway area checked by an LPA to be operational.
Continue on LIC809-C
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Angela Panushkina
LICENSING EVALUATOR SIGNATURE:

DATE: 08/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2024
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: CHATSWORTH ASSISTED LIVING
FACILITY NUMBER: 197610585
VISIT DATE: 08/23/2024
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Component III was conducted with the Administrator.

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 the license has been approved.

Exit interview was conducted and a copy of this report was provided to the Applicant/Administrator.

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Angela Panushkina
LICENSING EVALUATOR SIGNATURE:

DATE: 08/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2024
LIC809 (FAS) - (06/04)
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