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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610592
Report Date: 06/21/2024
Date Signed: 06/21/2024 12:27:59 PM

Document Has Been Signed on 06/21/2024 12:27 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
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:SECOND HOMEFACILITY NUMBER:
197610592
ADMINISTRATOR/
DIRECTOR:		HARUTYUNYAN ZARUHIFACILITY TYPE:
740
ADDRESS:18860 NAPA STREETTELEPHONE:
(818) 397-2656
CITY:NORTHRIDGESTATE: CAZIP CODE:
91324
CAPACITY: 6CENSUS: 0DATE:
06/21/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:36 AM
MET WITH:Zaruhi Harutyunyan- AdministratorTIME VISIT/
INSPECTION COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA) Mariana Agban conducted a Pre-Licensing Inspection with facility Administrator Zaruhi Harutyunyan. An application to operate a Residential Care Facility for the Elderly (RCFE) was received by Community Care Licensing (CCL) on March 08,2024. A fire clearance was approved on April 18, 2024 for a maximum capacity of five (5) non- ambulatory adults, one(1) Bedridden adult. Hospice waiver has been approved for six (6) hospice residents.

A tour of the physical plant was initiated at 9:35am and the following was observed:
The smoke alarms and carbon monoxide detector are hard wired and inter-connected. Fire extinguisher purchase date is 03/22/24.

KITCHEN: The facility has a Kitchen area that is equipped with a refrigerator, microwave oven and sink. There were adequate supplies of perishable and nonperishable food and dining ware to accommodate a maximum capacity of six (6) residents.
BEDROOMS: There are four (4) bedrooms designated for residents use. Two (2) bedrooms are designated to be shared rooms and two (2) bedrooms are designated to be private use . All bedrooms are furnished with beds, dressers and required bedding and linen. The bedrooms have sufficient closet space. Each bedroom had wearable lanyard emergency/ caregiver call button. BATHROOMS: The facility has one (1) main bathroom in the main hallway and one (1) in the bedroom #4 for the residents in that room to utilize. The hot water delivered in the bathroom sink was measured at 107.8 and 106.2 F. COMMON AREAS: These included the living room and dining room, which were equipped with furniture, a television, sofa. There is electric fireplace in the living room. It is non-operational. No fireplace tools or fixtures present. The auditory alarms on all exit doors were on and functional at the time of the visit. Laundry Area/ Garage: The washer/dryer appear to be in good condition. The laundry room will kept locked. Laundry cabinets was locked and thus laundry detergents are inaccessible to residents. LPA observed extra storage cabinets in the garage. MEDICATION: The medication will be kept in a locked in the kitchen cabinet. SURROUNDING GROUNDS: The driveway, passageways and entrance to the home was clear of obstruction.
(Continue 809C)
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Mariana Agban
LICENSING EVALUATOR SIGNATURE: DATE: 06/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/21/2024
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
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: SECOND HOME
FACILITY NUMBER: 197610592
VISIT DATE: 06/21/2024
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There is a car port large enough to park two cars. The backyard of the facility has a patio and backyard furniture to accommodate the six (6) residents. The facility backyard has sufficient yard space. There is no swimming pool or bodies of water. The side gate was checked to insure it was clear of obstruction.

Staff and resident files: Staff and resident files will be kept and maintained in a locked cabinet in the living room.


In addition to the Pre-Licensing inspection, a Component III power point presentation was also held.

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: Mariana Agban
LICENSING EVALUATOR SIGNATURE:

DATE: 06/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2024
LIC809 (FAS) - (06/04)
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