197610656-1-14-2025-31-AS-NSHN-DCWSUZ-20250114131159

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610656
Report Date: 01/14/2025
Date Signed: 01/14/2025 01:12:26 PM

Document Has Been Signed on 01/14/2025 01:12 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:	SUNSET SENIOR RESIDENCY		FACILITY NUMBER:	197610656
ADMINISTRATOR/ DIRECTOR:	KHACHATRYAN, MARI		FACILITY TYPE:	740
ADDRESS:	16328 BLACKHAWK STREET		TELEPHONE:	(818) 282-0819
CITY:	GRANADA HILLS	STATE: CA	ZIP CODE:	91344
CAPACITY: 6		CENSUS: 6	DATE:	01/14/2025
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	10:00 AM
MET WITH:	Mari Khachatryan, Ruzanna Manukyan		TIME VISIT/ INSPECTION COMPLETED:	01:15 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analysts (LPAs) Nadia Shahbazian and Michael Cava conducted a Pre-Licensing Inspection with the applicant Administrator, Mari Khachatryan and Designee Administrator, Ruzanna Manukyan at 10:00am. A change of ownership application to operate a Residential Care Facility for the Elderly (RCFE) was received by Community Care Licensing (CCL) on June 14, 2024. The facility is a one-story building. A fire clearance was approved on December 17, 2024 for five (5) non-ambulatory residents and one (1) bedridden resident, for a total capacity of six (6). Per STD 850, bedroom number one is appropriated for bedridden. The smoke alarms and carbon monoxide detector are dual and inter-connected. There are two fire extinguisher that were purchased on April 11, 2024, located by the dining room and the other near bedrooms 4 and 5. At approximately 10:30 am, with the assistance of the administrator, LPAs took a tour of the physical plant and the following was observed: KITCHEN: The kitchen is equipped with two refrigerators, stove/oven, microwave with a breakfast nook. There were adequate supplies of dining ware to accommodate a maximum capacity of six (6) residents. Knives were observed to be locked in a kitchen drawer. Currently 6 residents reside in the home and adequate supply of perishable and non-perishable food supplies were available. Cleaning supplies were locked underneath the sink.

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Nadia Shahbazian
LICENSING EVALUATOR SIGNATURE:	DATE: 01/14/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/14/2025

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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: SUNSET SENIOR RESIDENCY	FACILITY NUMBER: 197610656
	VISIT DATE: 01/14/2025

NARRATIVE

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BEDROOMS: There are five (5) bedrooms designated for client use, two (2) shared and three (3) private rooms. Per STD 850, bedroom one (1) is appropriated for bedridden with its own alarmed exit door. Bedrooms one (1) and shared (4) are shared and one (1), two (2) and three (3) are private. The applicant furnished each bedroom with a bed, night-stand, chair, dresser, bedding and linen. The bedrooms have sufficient lighting and closet space.

BATHROOMS: The facility has three (3) full bathrooms. Bedrooms #1 and has it's own private bathroom. The other two full bathrooms are in the hallway. The bathrooms were observed to have the proper fixtures, grab bars, non-skid mats and shower chairs. Bathrooms had adequate supply of linens and hygiene items. Hot water delivered in the bathrooms measured between 105.8 degrees.

COMMON AREAS: These included the living room and dining room areas. The living room has a couch, chair, table, and television. The dining room has a table large enough to seat six (6) residents. Activity area was located in the living room and there is an exit door leading to the backyard.

LAUNDRY ROOM: The laundry area is located in a separate, uncovered space, near room five (5). Laundry detergents were kept locked and inaccessible to residents.

MEDICATIONS: Medications were kept in a locked cabinet near the laundry area.

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Nadia Shahbazian
LICENSING EVALUATOR SIGNATURE:	DATE: 01/14/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/14/2025

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: SUNSET SENIOR RESIDENCY	FACILITY NUMBER: 197610656
	VISIT DATE: 01/14/2025

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SURROUNDING GROUNDS: The driveway, passageways and entrance to the home was clear of obstruction. All entry and exit doors have a functional auditory alert when the doors open. The backyard of the facility has a partial covered patios large enough to hold outdoor activities. There was adequate backyard furniture. There is no swimming pool, no garage. There is a locked shed, used to store supplies and furniture. The facility has cameras only for the front, back, and common areas of the home (visual only, no audio). No cameras in resident rooms or bathroom. The side gate leading to the backyard was free of obstruction and was designated for emergency entry/exit.

OFFICE/STAFF WORKSTATION: Staff workstation/office is located near the front entrance. The workstation consists of two filing cabinets to store resident and staff records, and a work desk. Located within the workstation, is a lounge area with a couch, two chairs and a television. Facility is equipped with internet access and land line telephone.

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: Nadia Shahbazian
LICENSING EVALUATOR SIGNATURE:	DATE: 01/14/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/14/2025

LIC809 (FAS) - (06/04)

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