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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603526
Report Date: 11/23/2021
Date Signed: 11/23/2021 10:14:33 AM

Document Has Been Signed on 11/23/2021 10:14 AM - 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:SUNNY GARDEN SENIOR CARE LLCFACILITY NUMBER:
198603526
ADMINISTRATOR:BARSEGHYAN, ARAMFACILITY TYPE:
740
ADDRESS:1019 RALEIGH STTELEPHONE:
(747) 270-7638
CITY:GLENDALESTATE: CAZIP CODE:
91205
CAPACITY: 6CENSUS: 0DATE:
11/23/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Aram Barseghyan; ApplicantTIME COMPLETED:
10:30 AM
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Licensing Program Analyst (LPA) David Sicairos conducted an announced Pre-Licensing facility Evaluation visit. LPA met with Applicant Aram Barseghyan who assisted with the visit. The home is located in a residential neighborhood within the city of Glendale and is a one story building which consists of five (5) bedrooms, three (3) bathrooms, living room, dining room, kitchen, and detached garage. The home has a fire clearance from the local Fire Department for a capacity of five (5) non-ambulatory and one (1) bedridden resident ages 60 and over.

The following was inspected during the evaluation with Mr. Barseghyan and determined to be compliant with the California Code of Regulations Title 22. A locked storage area for central storage of medications was observed in the kitchen. Cleaning supplies were separate from where food supplies are stored. The walls, ceilings, floors, window screens and areas around the facility were clean and in good repair. A locked storage area under the kitchen sink for cleaning solutions and disinfectants was observed. A fire extinguisher was located in the dining room of the home. (2) Carbon monoxide detectors were observed throughout the facility. Smoke detectors were observed throughout the facility and were tested and operable. Doors, exits, hallways, and passageways were clear and free of obstruction. The front and back yards were observed to be clean and free of debris. No pools or bodies of water were observed in or around the home. There are no firearms present at the facility. An operating telephone was observed on the premises, which is easily accessible and available for resident use. The first-aid kit was observed and is kept in the kitchen, which included all required supplies. The refrigerator was observed to be at 45 degrees Fahrenheit and the freezer at 0 degrees Fahrenheit.

Food storage and preparation areas, which includes pantries, cupboards, drawers and counters were observed to be clean and appropriate for food preparation. Appliances such as a microwave, refrigerator and stove were observed to be clean and operating properly. Food utensils, dishes and glasses were clean and sufficient for the number of clients to be served. (CONTINUED ON 9099C)

SUPERVISORS NAME: Rebecca Orendain
LICENSING EVALUATOR NAME: David Sicairos
LICENSING EVALUATOR SIGNATURE: DATE: 11/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/23/2021
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: SUNNY GARDEN SENIOR CARE LLC
FACILITY NUMBER: 198603526
VISIT DATE: 11/23/2021
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Hot water temperature was tested in bathroom #1 and read 116.5F which is within the required 105F - 120F. The outdoor patio in the backyard was observed to have well shaded area and was furnished for outdoor use. Bedrooms have a mattress, pad, bedsprings, and a pillow which were clean. Each bed had a clean fitted sheet, pillowcase, blanket and bedspread. It was observed that resident bedrooms had adequate dresser and closet space for clothing and other belongings.

A sufficient supply of linens to permit weekly changing or more often to insure clean linens at all times for residents were observed to be kept in the hall linen closet. Equipment and supplies for client personal hygiene was observed to be made available on site. Employee and Resident files will be maintained and locked in a cabinet located in the kitchen.

The Component III orientation was also conducted during today's visit. No outstanding or pending items were observed by LPA requiring additional pre-licensing visits.

LPA will notify the assigned Centralized Applications Bureau (CAB) Analyst of the completed pre-licensing facility evaluation visit conducted, which included the Component III orientation. Exit interview conducted and a copy of this report was provided to Applicant.
SUPERVISORS NAME: Rebecca Orendain
LICENSING EVALUATOR NAME: David Sicairos
LICENSING EVALUATOR SIGNATURE:

DATE: 11/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/23/2021
LIC809 (FAS) - (06/04)
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