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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603386
Report Date: 03/16/2022
Date Signed: 03/16/2022 12:58:51 PM

Document Has Been Signed on 03/16/2022 12:58 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, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:ALAMEDA VILLAFACILITY NUMBER:
198603386
ADMINISTRATOR:LEKHLYAN, CHRISTINEFACILITY TYPE:
740
ADDRESS:1433 E. ALAMEDA AVETELEPHONE:
(818) 331-6331
CITY:BURBANKSTATE: CAZIP CODE:
91501
CAPACITY: 6CENSUS: DATE:
03/16/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:17 AM
MET WITH:Anahit Saakyan and Art SaakyanTIME COMPLETED:
01:20 PM
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Licensing Program Analysts (LPA) Jewel Baptiste conducted an unannounced visit for the purpose of conducting the required annual inspection. On today's visit LPA met with S1 and S2 who stated that they currently living at the facility and the facility is not taking residents at this time. Administrator Christine called LPA and confirmed their statement. The administrator stated that S1 and S2 are in the middle of finding another location to live. The administrator stated the reason why their facility is operating is because they must submit documents to the Regional Center, and it will take another year for the regional center to provide clients. Administrator stated she will get clearance and association for S1 and S2. At 10:20 administrator Christine joined the visit.

Facility is licensed to serve 6 clients 60 years and over. 6 of which shall be non- ambulatory. Hospice wavier approved for 6. The facility is a single story building in a residential area, with a commercial kitchen, dining room, living room, 6 bedrooms, 4 bathroom and 1 office. The backyard shaded sitting area. Facility has a fire sprinkler system throughout the facility.

LPAs discussed infection control practices with administrator, toured the facility inside and out, reviewed food supply. There are no staff files, and resident medications to review due to not accepting residents at this time.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Jewel Baptiste
LICENSING EVALUATOR SIGNATURE: DATE: 03/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/16/2022
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, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: ALAMEDA VILLA
FACILITY NUMBER: 198603386
VISIT DATE: 03/16/2022
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Bedrooms have the required furniture including bedframes, dressers, lamps, and chairs. Beds have the required linen and the linen is in good condition. LPA toured the kitchen and observed the facility do not have 7 days of perishables and 2 days non perishable due to the facility not accepting residents at this time. Passageways and exits are free of obstruction. The front and backyard are well maintained. The resident bathrooms are clean, and showers have required grab bars. The hot water temperature measured at 113-114.3 degrees F. The facility temperature at the time the visit was comfortable. There is sufficient lighting throughout the facility. There are smoke detectors located throughout the facility, tested and operational. Carbon monoxide detector was also observed, tested and operational. LPA observed a sufficient supply of PPE in garage. Infection control signs were not observed throughout the facility and sign in station were not observed at the facility.

An action plan will be submitted to Licensing regarding how the licensee plan to stay operating and when they will start to receive residents by 3/25/22.

Per California Code of Regulations, Title 22, and California Health and Safety Code, there were Technical Advisory observed during the visit. Exit interview held and a copy of the report was provided to administrator.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Jewel Baptiste
LICENSING EVALUATOR SIGNATURE:

DATE: 03/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/16/2022
LIC809 (FAS) - (06/04)
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