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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603787
Report Date: 11/21/2024
Date Signed: 12/05/2024 09:11:42 PM

Document Has Been Signed on 12/05/2024 09:11 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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:VARDA HOME INCFACILITY NUMBER:
198603787
ADMINISTRATOR/
DIRECTOR:		MARKOSIAN, ARMENFACILITY TYPE:
740
ADDRESS:1744 E ELIZABETH STTELEPHONE:
(818) 913-1742
CITY:PASADENASTATE: CAZIP CODE:
91104
CAPACITY: 6CENSUS: 0DATE:
11/21/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:TIME VISIT/
INSPECTION COMPLETED:
11:15 AM
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Licensing Program Analyst (LPA), Sanjay Vaid conducted an announced visit to the facility for purpose of a Pre-licensing evaluation. At today's visit Administrator Armen Markosian and consultant Ripa Tavitian were present. An application was submitted to CCLD for Initial license for RCFE. The requested capacity is for 5non-ambulatory and 1 bedridden resident.

Structure: The facility is a single story house and located in a residential neighborhood area. Facility is 4 bedrooms, 2 bathrooms, kitchen, living room, staff office/dining area and Activity Room. The client bedrooms are spacious and will easily accommodate the client's furnishings. The yard has a covered, shaded area for table and chairs. The passageways, walkways, driveway are free from obstructions. The front, back and side areas are free of hazards and maintained in a good condition.

Signal system: The facility has a delayed egress with key and code to enter into the facility and LPA observed and its operational.

Bedrooms Residents: There is one bed in each client's bedroom. Each bedroom has one beds, one chairs, one night stand, one dresser, one closet and overhead lighting.

Bathrooms: All toilet, wash basins and showers are working.

Linens & Hygiene Supplies: Beds have the required linen/supplies which include, pillowcase, mattress pads, fitted sheet, blanket and bedspreads. Adequate supply of linen stored in client's closet and the personal hygiene supplies will be stored and locked in the file cabinet in the living room.

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SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Sanjay Vaid
LICENSING EVALUATOR SIGNATURE: DATE: 11/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/21/2024
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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: VARDA HOME INC
FACILITY NUMBER: 198603787
VISIT DATE: 11/21/2024
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Emergency Phone Numbers, Exit Plan: The facility has a landline phone # and the phone number is (626) 888-7858. Tested & readily available for use in staff office. Fire Extinguisher located in the kitchen mounted on wall.
Food Service: Dishes, cups and flat ware are stored in the kitchen cabinets, inspected and in good repair. Knives, cutlery and other sharp kitchen utensils are stored and locked in a kitchen cabinet. Food supply adequate stored in the kitchen and consists of the following: 2 days perishable and 7 days non-perishable.
Smoke Detectors: There are six smoke detector/carbon monoxide detector(s) were tested & are inter-connected.
Appliances: Stove burners, oven, microwave, washer, and dryer working properly. Each refrigerator has a measured temperature of at least 45 degrees Fahrenheit for appropriate food storage. Freezer is at (0) zero degrees Fahrenheit. The client's bedroom is equipped with central air and heat.
Toxins: All cleaning supplies and toxins are locked and stored under the sink and in the laundry room.
Water Temperature: The hot water temperature in bathroom and kitchen was tested and measured between 105 and 120 degree degrees Fahrenheit as required.
Medications, First-Aid Kit & Book: A first aid kit has been inspected which has at least the following: thermometer, tweezers, scissors, antiseptic, bandages, gauze and current first aid manual, which are stored and locked in a kitchen cabinet, available for staff use but inaccessible to clients. Clients' medication is centrally stored and locked in the cabinet.
Clients & Staff Files:
Records of staff and clients shall be stored in a locked file cabinet in the staff room. The client and staff files are stored and locked in the file cabinet in the office /dining room.

Component III: Administrator has other facility and waived the component III presentation facility compliance.
An exit interview was conducted and a copy of this report has been furnished to the applicant. Accordingly, LPA will submit a copy of this facility evaluation report to the Central Applications Bureau (CAB) for review. If the applicant has questions regarding the status of the application, they have been instructed to communicate with the CAB Analyst assigned to their application.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Sanjay Vaid
LICENSING EVALUATOR SIGNATURE:

DATE: 11/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2024
LIC809 (FAS) - (06/04)
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