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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610660
Report Date: 11/13/2024
Date Signed: 11/13/2024 01:22:08 PM

Document Has Been Signed on 11/13/2024 01:22 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:NORTH HILLS CAREFACILITY NUMBER:
197610660
ADMINISTRATOR/
DIRECTOR:		HARUTYUNYAN, LILITFACILITY TYPE:
740
ADDRESS:9332 ODESSA AVENUETELEPHONE:
(818) 653-9371
CITY:NORTH HILLSSTATE: CAZIP CODE:
91343
CAPACITY: 6CENSUS: 0DATE:
11/13/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:23 AM
MET WITH:Gayk Kazaryan, Lilit HarutyunyanTIME VISIT/
INSPECTION COMPLETED:
01:30 PM
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Licensing Program Analyst (LPA) Michael Cava conducted a Pre-Licensing Inspection with the applicant representative, Gayk Kazaryan, and administrator, Lilit Harutyunyan. An Application to operate a Residential Care Facility for the Elderly (RCFE) was received by Community Care Licensing (CCL) on June 25, 2024. A fire clearance was approved on August 19, 2024 for five (5) non-ambulatory residents and one (1) bedridden resident, for a total capacity of six (6). The applicant is also requesting a hospice waiver to retain six (6) residents. The smoke alarms and carbon monoxide detector are dual and inter-connected. The facility has a new fire extinguisher located by the kitchen. It was purchased on June 26, 2024.

A tour of the physical plant was initiated after the Component III presentation, which was also held in conjunction with the Pre-Licensing visit. The facility is a one story building.

KITCHEN: The facility has a Kitchen area that is equipped with a refrigerator, stove/oven, microwave oven and sink. There is an adequate supply of nonperishable food items. Perishable food items not required at this time as there are no residents. Applicant and administrator was made aware to supply the facility with perishable foods once they admit their first resident. There is sufficient dining ware to accommodate a maximum capacity of six (6). Knives were observed locked in a kitchen drawer. Cleaning supplies will be kept locked underneath the kitchen sink.

BEDROOMS: There are four (4) bedrooms designated for client use. Bedroom #1 and #2 are private, with bedroom #1 only having a bedridden fire clearance (per STD 850). Bedrooms #3 and #4 are shared. The applicant furnished the resident bedrooms with beds, night stand, chairs, dresser, bedding and linen. The bedrooms have sufficient lighting and closet space.

BATHROOMS: The facility has three (3) bathrooms. Bedrooms #3 and #4 has it's own bathroom with shower. The other bathroom is located in the hallway by bedroom #1 and #2. The bathrooms were
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Michael Cava
LICENSING EVALUATOR SIGNATURE: DATE: 11/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/13/2024
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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: NORTH HILLS CARE
FACILITY NUMBER: 197610660
VISIT DATE: 11/13/2024
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observed to have the proper fixtures, grab bars, and non-skid mats. The hot water delivered in the bathrooms measured between 105 to 110 degrees.


COMMON AREAS: These included the living room and dining room. The living room is furnished with three couches, a coffee table, two additional side tables and a television. There is a fireplace with a screen that is non-operational. No fireplace tools or fixtures present. The dining room table is large enough to accommodate up to six (6) residents.

GARAGE: Per STD 850, garage to be maintained as a garage only. Entry is kept locked, and is through the staff office or at the side of the home. Garage will be used for storage. No resident access.

LAUNDRY: The laundry area is located in the garage, where detergents and cleaning agents will be kept.

OFFICE/STAFF WORKSTATION: Staff workstation is located in the hallway by Rooms #1 and #2. Staff and resident records will be kept in a locked cabinet there. Office will also be kept locked and inaccessible to the residents.

MEDICATIONS: Medications will be kept in a locked cabinet in staff office/workstation.

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 patio and backyard furniture to accommodate the six (6) residents. The facility backyard has sufficient yard space. There is no swimming pool. The front has an exterior gate, but it will not be kept locked.

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: Michael Cava
LICENSING EVALUATOR SIGNATURE:

DATE: 11/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/13/2024
LIC809 (FAS) - (06/04)
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