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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610595
Report Date: 12/09/2024
Date Signed: 12/09/2024 01:33:59 PM

Document Has Been Signed on 12/09/2024 01:33 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:AYLA HOUSE FOR ELDERLY CAREFACILITY NUMBER:
197610595
ADMINISTRATOR/
DIRECTOR:		KORDONSKIY, ELENAFACILITY TYPE:
740
ADDRESS:226 S GRIFFITH PARK DRTELEPHONE:
(818) 919-1234
CITY:BURBANKSTATE: CAZIP CODE:
91506
CAPACITY: 6CENSUS: 4DATE:
12/09/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:25 AM
MET WITH:Elena KordonskiyTIME VISIT/
INSPECTION COMPLETED:
01:30 PM
NARRATIVE
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On 12/09/24, at 09:25am, Licensing Program Analyst (LPA) Gina Saucedo conducted an announced Pre-licensing visit. LPA's met with Administrator Elena Kordonskiy at 9:25 am.

An application was submitted to Community Care Licensing Division-CCLD on 02/29/2024, Initial license for a Residential Care Facility for the Elderly (RCFE), 60 years and older. The requested capacity is for six (6) ambulatory ONLY.

Structure: The facility is a single-story building with three (3) bedrooms and two (2) bathrooms.

Entrance: There is only one (1) entrance being utilized. Required postings such as: Personal Rights of Residents, Emergency and Disaster Plan, Yes sign, Ombudsman, Resident Infection Control are on your left hand side of the facility.

Toxins, cleaning solutions, and laundry detergents are kept locked and inaccessible to residents in a cabinet in the bathroom.

Living/Dining area: The living room is neat, clean, and organized with sufficient seating for both residents and staff. The dining area is also neat, clean, and organized. Both rooms are properly furnished and in good repair. The facility maintains a comfortable temperature of seventy-one (71) degrees. No firearms observed or will be maintained on the premises.

Resident/staff files: Resident and staff files are currently locked in a cabinet in the kitchen.

LIC809C-continued

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Gina Saucedo
LICENSING EVALUATOR SIGNATURE: DATE: 12/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/09/2024
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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: AYLA HOUSE FOR ELDERLY CARE
FACILITY NUMBER: 197610595
VISIT DATE: 12/09/2024
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Kitchen: Sufficient supplies of dishes, cups, and silverware located within the kitchen cabinets and drawers. Sharps are stored on the left side of the kitchen locked and inaccessible to the residents. Sufficient supply of food such as: canned goods, bottles of water, cereal were observed in the garage. Kitchen appliances are working and are in good repair. First-aid kit observed as well in the kitchen. There is a working telephone on the premises on the kitchen counter.

Emergency: Fire extinguisher located in the kitchen on the left side and dated 12/07/2024.

Medications: Medication is stored in the kitchen cabinet on your right hand side. The medication is currently kept in kitchen cabinet locked and inaccessible to the current residents.

Bedrooms: The bedrooms are properly furnished with bed, nightstand, applicable lightening, and seating. Window coverings are in good repair, not broken or damaged. All the bedrooms are shared. There are three (3) bedrooms that are currently occupied.

Bathroom: The bathrooms are in proper condition and will be equipped with sufficient personal hygiene for each client. Towels and washcloths will not be shared.

Hallways: Hallway is properly lighted.

Staff room: There is no designated staff bedroom in the facility.

Water Temperature: The water temperature was measured in the bathrooms at 118.8 Fahrenheit and is within regulations.

LIC809C-continued

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Gina Saucedo
LICENSING EVALUATOR SIGNATURE:

DATE: 12/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2024
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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: AYLA HOUSE FOR ELDERLY CARE
FACILITY NUMBER: 197610595
VISIT DATE: 12/09/2024
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Smoke detectors: Dual interconnected smoke detectors and carbon monoxide observed to be working properly and were tested.

There is no garage but there is an Accessory Dwelling Unit (ADU) in the back of the house detached from the home that will be used for staff living which is not on the facility sketch. The administrator/Licensee is aware that ADU has to be available for LPA observation and everyone living in the ADU has to be fingerprinted and have a background clearance. LPA did have access to the ADU at the time of the tour.

Outside: The outside is clean, free of hazards, and will be properly furnished with sufficient seating. A shaded area for residents was observed as well.



Pool: no bodies of water located at the facility.

Administration: The facility had submitted an Emergency and Disaster Plan For Residential Care Facilities For The Elderly and Infection plan.

The Component III Orientation RCFE was shown/reviewed with the Administrator.

At this time, the facility is in compliance with Title 22 Regulations at this time. This report will be forwarded to the Centralized Application Bureau (CAB). You will be notified by the CAB Analyst when your license has been approved.

Be advised, this was a unlicensed facility and they have now applied for a license. There is currently four (4) residents that ambulatory. The Administrator Elena Kordonskiy is currently the staff.

Exit interview conducted and copy of this report issued to the administrator.

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Gina Saucedo
LICENSING EVALUATOR SIGNATURE:

DATE: 12/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2024
LIC809 (FAS) - (06/04)
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