<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603493
Report Date: 02/04/2025
Date Signed: 02/04/2025 03:36:18 PM

Document Has Been Signed on 02/04/2025 03:36 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:MOON LIGHT BOARDING CARE INCFACILITY NUMBER:
198603493
ADMINISTRATOR/
DIRECTOR:		SAKO MANVELYANFACILITY TYPE:
740
ADDRESS:120 N SIERRA BONITA AVETELEPHONE:
(818) 661-7333
CITY:PASADENASTATE: CAZIP CODE:
91106
CAPACITY: 6CENSUS: 3DATE:
02/04/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:25 PM
MET WITH:Asmik Avetisyan - CaregiverTIME VISIT/
INSPECTION COMPLETED:
03:50 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 Analyst (LPA) Mary Flores conducted an unannounced annual visit at the facility using the CARE inspection tool. LPA met with Asmik Avestisyan and explained the reason for the visit.

The facility is licensed to served (6) non-ambulatory residents over the age of 60, of which (1) may be bedridden, with a hospice waiver for (4). The facility is a single home located in a residential neighborhood and consist of a living/dining room area, a kitchen, (4) resident bedrooms, (4) resident bathrooms, (1) staff/visitor's bathroom, a front porch, a backyard, and a detached garage.

LPA toured the facility with Asmik Avetisyan and observed the following:
Facility is in good repair indoor and outdoor. All passageways are free of debris. There are no large bodies of water. Living room and dining room are furnished to provide seating area and activities for the residents. Activities were observed in the living room. Kitchen was observed clean and in working condition. There is sufficient food supplies for at least 2 days of perishables and 7 days of non-perishables. Cleaning supplies, sharps and medications are kept locked in kitchen cabinets. Four (4) resident bedrooms were observed with sufficient lighting, the required furniture, and bedding supplies. A total of (4) bathrooms were observed in working condition, with grab bars and skid mats. Water temperature was tested in each bathroom between 106.8-116.7 degrees F., which is within the required 105-120 degrees F. Carbon monoxide/smoke detectors were tested and are in working condition. Fire extinguisher was observed and last reviewed on 1/14/25. All requires posters were observed. Facility has a porch that provides a shaded area as well as a clean backyard. Laundry is located in the basement. Exit doors have an auditory device.

LPA reviewed medication and files for 3 residents. There are currently zero (0) residents on hospice or with dementia. Resident #3(R3) is missing a TB test clearance. Bed rails were observed in the beds of Resident #1and #3 (R1/R3), no physician's request on file.
(CONTINUED ON LIC 809C)
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Mary G Flores
LICENSING EVALUATOR SIGNATURE: DATE: 02/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/04/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: MOON LIGHT BOARDING CARE INC
FACILITY NUMBER: 198603493
VISIT DATE: 02/04/2025
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
26
27
28
29
30
31
32
LPA reviewed 2 staff files. Administrator's file was not at the facility at the time of the visit. Staff #3(S3) was missing TB clearance results on health screening, physician noted read date but did not note results. S3 was hired on 1/5/25 and has been working since January 14, 2025, there are no records of fingerprint clearance. Administrator certificate was reviewed for Sako Manvelyan #6066207740 exp. date: 9/8/25.

LPA Flores reviewed infection control plan and emergency disaster plan. Last fire drill was conducted on 12/16/24 and are being conducted quarterly.

Deficiencies are noted on LIC 809D per Title 22 Regulations.

*Civil penalties were assess for $500.00 for background clearance.*

Exit interview was conducted with Administrator and a copy of this report, LIC 809D, and appeal rights were provided.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Mary G Flores
LICENSING EVALUATOR SIGNATURE:

DATE: 02/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/04/2025
LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 02/04/2025 03:36 PM - It Cannot Be Edited


Created By: Mary G Flores On 02/04/2025 at 02:59 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: MOON LIGHT BOARDING CARE INC
FACILITY NUMBER: 198603493

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/04/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87355(e)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview, and record review, the licensee did not comply with the section cited above in S3 does not have a fingerprint clearance which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/05/2025
Plan of Correction
1
2
3
4
Administrator requested staff to leave for the day and will wait until clearance for S3 for staff to return to work. *Civil penalties were assess for $500.00.*
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Tony Vasallo
LICENSING EVALUATOR NAME:Mary G Flores
LICENSING EVALUATOR SIGNATURE:
DATE: 02/04/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/04/2025


LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 02/04/2025 03:36 PM - It Cannot Be Edited


Created By: Mary G Flores On 02/04/2025 at 02:59 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: MOON LIGHT BOARDING CARE INC
FACILITY NUMBER: 198603493

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/04/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(g)
Personnel Records
(g) All personnel records shall be maintained at the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on interview and record review, the licensee did not comply with the section cited above in administrator's file was not at the facility at the time of the visit which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/11/2025
Plan of Correction
1
2
3
4
Administrator will ensure all files are kept at the facility at all times and will provide a copy of administrator's file to the department by POC due date 2/11/25.
Type B
Section Cited
CCR
87458(b)(1)
Medical Assessment
(b) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the physician's primary diagnosis and secondary diagnosis, if any and results of an examination for communicable tuberculosis, other contagious/infectious or contagious diseases or other medical conditions which would preclude care of the person by the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in R3 does not have a TB test clearance on file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/11/2025
Plan of Correction
1
2
3
4
Administrator will obtain a TB test clearance for R3 and will submit a copy to the department by POC due date 2/11/25.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Tony Vasallo
LICENSING EVALUATOR NAME:Mary G Flores
LICENSING EVALUATOR SIGNATURE:
DATE: 02/04/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/04/2025


LIC809 (FAS) - (06/04)
Page: 4 of 6
Document Has Been Signed on 02/04/2025 03:36 PM - It Cannot Be Edited


Created By: Mary G Flores On 02/04/2025 at 02:59 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: MOON LIGHT BOARDING CARE INC
FACILITY NUMBER: 198603493

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/04/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87608(a)(5)(A)
Postural Supports
(A) A bed rail that extends from the head half the length of the bed and used only for assistance with mobility shall be allowed.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and record review, the licensee did not comply with the section cited above in 2 out of 3 residents do not have physician's bed rail request on file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/18/2025
Plan of Correction
1
2
3
4
Administrator will request a physician's order/request for half bed rails for R1 and will send an exception request for R3 along with physician's bed rail request, physician's letter, and physician's report to the department by POC due date 2/18/25.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Tony Vasallo
LICENSING EVALUATOR NAME:Mary G Flores
LICENSING EVALUATOR SIGNATURE:
DATE: 02/04/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/04/2025


LIC809 (FAS) - (06/04)
Page: 5 of 6