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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610630
Report Date: 11/19/2024
Date Signed: 11/19/2024 02:10:31 PM

Document Has Been Signed on 11/19/2024 02:10 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:ASH ENTERPRISES LLCFACILITY NUMBER:
197610630
ADMINISTRATOR/
DIRECTOR:		SHAHVERDIAN, ARLENFACILITY TYPE:
740
ADDRESS:1332 PASTEUR DRIVETELEPHONE:
(818) 469-2001
CITY:LANCASTERSTATE: CAZIP CODE:
93535
CAPACITY: 6CENSUS: 0DATE:
11/19/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Arlen ShahverdianTIME VISIT/
INSPECTION COMPLETED:
02:30 PM
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On 11/19/2024 at 09:30 am, Licensing Program Analyst (LPA) Lorena Casillas conducted an announced Pre-Licensing Inspection with Licensee Arlen Shahverdian and Administrator Artisha Hickman. An application to operate a Residential Care Facility for the Elderly (RCFE) was received by Community Care Licensing (CCL) on 05/09/2024. A fire clearance was approved on 8/20/2024, for four (4) non-ambulatory residents and two (2) ambulatory residents for a total capacity of six (6). The purpose of today’s visit is to inspect the facility to ensure that it maintains compliance under California Code of Regulations, Title 22, Division 6.

The Component III presentation was conducted from 10:15 am until 12:05 pm with Licensee and Administrator.

A tour of the physical plant was initiated at approximately 01:00 pm and the following was observed:

KITCHEN: The facility has a Kitchen area that is equipped with a refrigerator, microwave oven and sink. There was an adequate supply of nonperishable food and dining ware to accommodate a maximum capacity of six (6). Perishable food will be purchased once residents are established. Knives will be locked in a kitchen drawer.

BEDROOMS: The facility has three (3) bedrooms for resident use. Bedroom #1 and Bedroom #3 are designated for two (2) non ambulatory residents each. Bedroom #2 is designated for two (2) ambulatory residents.
The applicant furnished the resident bedrooms with beds, nightstand, chairs, dresser, bedding and linens. All rooms had sufficient lighting.

BATHROOMS: The facility has two (2) bathrooms. All bathrooms were observed to have the proper fixtures, and non-skid mats. The hot water delivered in the bathrooms measured 119.6 degrees F.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Lorena Casillas
LICENSING EVALUATOR SIGNATURE: DATE: 11/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/19/2024
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: ASH ENTERPRISES LLC
FACILITY NUMBER: 197610630
VISIT DATE: 11/19/2024
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COMMON AREAS: These included the living room and dining room areas, which were equipped with living room furniture, a television, tables, and chairs. The dining room table is large enough to accommodate up to six (6) residents. There were no visible immediate hazards. The smoke alarms are hard wired and inter-connected. The carbon monoxide detector is functional. The facility has one fire extinguisher that was purchased on 10/18/2024 and is fully charged that is located in the kitchen.

LAUNDRY ROOM: Laundry room has washer and dryer. Cleaning detergents and supplies are locked in the garage.

MEDICATIONS: Medications and first aid kit will be stored in a locked cabinet in the kitchen area.

GARAGE: The garage is used for storage. There is a refrigerator used for extra food and water.

STAFF/RESIDENT RECORDS: Staff and resident records will be stored in a locked cabinet, located in the living room. The applicant was advised to ensure that resident and staff records will be accessible to the licensing agency upon request or during inspection.

SURROUNDING GROUNDS: The driveway, passageways and entrance to the home was clear of obstruction. The backyard of the facility has a patio and backyard furniture. The facility backyard has sufficient yard space to accommodate outdoor activities. There is no swimming pool or bodies of water.

Exit Interview was conducted, and a copy of this report was given to applicant.

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Lorena Casillas
LICENSING EVALUATOR SIGNATURE:

DATE: 11/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2024
LIC809 (FAS) - (06/04)
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