197610686-1-16-2025-31-AS-ASEA-DCYRMH-20250116120846

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610686
Report Date: 01/16/2025
Date Signed: 01/16/2025 12:08:57 PM

Document Has Been Signed on 01/16/2025 12:08 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:	ARK'S VILLA		FACILITY NUMBER:	197610686
ADMINISTRATOR/ DIRECTOR:	NAZARI, GAMER JIM		FACILITY TYPE:	740
ADDRESS:	26860 LUGAR DE ORO DRIVE		TELEPHONE:	(818) 321-7772
CITY:	VALENCIA	STATE: CA	ZIP CODE:	91354
CAPACITY: 6		CENSUS: 0	DATE:	01/16/2025
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	10:00 AM
MET WITH:	Gamer Jim Nazari- Administrator		TIME VISIT/ INSPECTION COMPLETED:	12:30 PM

NARRATIVE

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On 1/16/25, at 10:00 AM, Licensing Program Analyst (LPA) Angelica Segovia conducted an announced Pre-licensing visit. LPA Segovia met with Administrator Gamer Jim Nazari.

An application was submitted to Community Care Licensing Division-CCLD on 06/20/2024, Initial license for a Residential Care Facility for the Elderly (RCFE), 60 years and older. The pending facility will have a Dementia Care Program. The requested capacity is for five (5) non-ambulatory and one (1) bedridden, total of up to six (6) residents, and Hospice waiver for six (6) residents. Fire clearance was approved on 11/14/2024.

Structure: The facility is a single-story building with five (5) bedrooms and two (2) bathrooms. One (1) room will be designated staff room only.

Entrance: There is only one (1) entrance being utilized. Required postings such as: Personal Rights of Residents, Rights of Resident by Council, Family Council, Infection Control, Emergency and Disaster Plan, Facility Sketch, Theft and Loss Policy, House Rules, Non-discrimination Policy and See Something Say Something are posted upon entry.

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 (70) degrees. No firearms observed or will be maintained on the premises. There is a working telephone on the premises.

Fireplace: LPA observed fireplace covered and inaccessible to residents.

Resident/staff files: Resident and staff files will be kept in the office located near the garage. Files will be kept in a locked cabinet inaccessible to Residents. First-aid kit observed as well.

LIC809C-continued

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Angelica Segovia
LICENSING EVALUATOR SIGNATURE:	DATE: 01/16/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/16/2025

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: ARK'S VILLA	FACILITY NUMBER: 197610686
	VISIT DATE: 01/16/2025

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Kitchen: Sufficient supplies of dishes, cups, and silverware located within the kitchen cabinets and drawers. Sharps are stored in kitchen drawer locked and inaccessible to the residents. Sufficient supply of food such as: canned goods, bottles of water, cereal were observed. Kitchen appliances are working and in proper condition.

Emergency: Fire extinguisher located upon entrance to the kitchen on the right side and dated 8/07/2024.

Medications: Medication will be stored in a locked drawer in the kitchen. Medication storage is equipped with a lock to ensure medications will not be accessible to residents.

Bedrooms: The bedrooms are properly furnished with bed, nightstand, applicable lightening, and seating. Window coverings are in good repair, not broken or damaged. LPA observed a signal systems in each bedroom windows, working and in proper condition.

Bathroom: The bathrooms are in proper condition and will be equipped with sufficient personal hygiene for each resident. Towels and washcloths will not be shared. Appropriate grab-rails and slip-resistant mats observed and in proper condition.

Hallways: Hallway is properly lighted. Extra linens/covers observed in storage cabinet within the passageway.

The Garage: The garage can be accessed from inside the facility. It is kept locked. The garage will be used for extra storage, Cleaning solutions, Laundry detergents, extra food for emergencies, and extra personal hygiene supplies. There is an extra refrigerator and freezer. Both working and in proper condition.

Laundry: Laundry is located inside the garage. Dryer and washer observed to be in good repair.

Staff room: LPA observed designated staff room located near staff office. Staff room observed locked inaccessible to residents.

Office: LPA observed staff reception office located near staff room.

Water Temperature: The water temperature was measured in the bathrooms at 115 Fahrenheit and is within regulations.

LIC809C-continued

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Angelica Segovia
LICENSING EVALUATOR SIGNATURE:	DATE: 01/16/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/16/2025

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: ARK'S VILLA	FACILITY NUMBER: 197610686
	VISIT DATE: 01/16/2025

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Smoke detectors: Dual interconnected smoke detectors and carbon monoxide observed to be working properly and were tested at 11:00 am.

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

Pool: Pool was observed to be fenced and locked inaccessible to residents.

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

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

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.

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

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Angelica Segovia
LICENSING EVALUATOR SIGNATURE:	DATE: 01/16/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/16/2025

LIC809 (FAS) - (06/04)

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