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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881617
Report Date: 08/28/2024
Date Signed: 08/28/2024 01:48:29 PM

Document Has Been Signed on 08/28/2024 01:48 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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:LUNA SENIOR SERVICESFACILITY NUMBER:
331881617
ADMINISTRATOR/
DIRECTOR:		HOVSEPIAN, SAHAKFACILITY TYPE:
740
ADDRESS:2121 E DESERT PARK AVENUETELEPHONE:
(818) 568-6812
CITY:PALM SPRINGSSTATE: CAZIP CODE:
92262
CAPACITY: 6CENSUS: 0DATE:
08/28/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:25 PM
MET WITH:Sahak Hovsepian, applicantTIME VISIT/
INSPECTION COMPLETED:
02:00 PM
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Licensing Program Analysts (LPAs), Seo Jeon and Ferrer Sabarias conducted an announced pre-licensing inspection at the home. The LPAs met with Applicants, Sahak Hovsepian. There are currently no residents in care.

The application is for a Residential Care Facility for the Elderly. The fire clearance has been granted for six (6) ambulatory residents of which five (5) may be non-ambulatory and one(1) may be bedridden.

The home is composed of four (4) resident bedrooms, three (3) bathrooms, a garage, laundry room, living room, an open kitchen and dining area, and front and back yard areas. The interior and exterior walkways of the home were observed to be clutter free with no obstructions present. Smoke and Carbon Monoxide detectors were tested and operable. New fire extinguisher is located near the kitchen area. Swimming pool in the backyard is in compliance with fence all around and locked gate. Per the applicant, there is no known firearms. Rooms, furniture, beds, mattresses were all in good repair. The bedrooms are furnished, and privacy is available. The dining and living room areas are clutter free and furniture is in good condition. The resident bathrooms were observed to have non-slip mats available and showers are equipped with non-slip surface. The hot water was tested and measured at 110 degrees Fahrenheit, which is within regulatory requirements. Outdoor areas had sufficient room for activities. A washing machine and dryer are available and in working order.

Activities were observed to be available. Medications will be stored inaccessible to any unauthorized individuals. Designated areas are available for facility files, staff files and resident files. The first aid kit was observed to be available and complete with manual. Cleaning supplies will be stored away in a locked area. Linens, and equipment are all in good repair and sufficient for approved census. A Fire extinguisher was available and fully charged. The facility has working telephone for client use.

Continued on LIC809-C......

SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Seo Jeon
LICENSING EVALUATOR SIGNATURE: DATE: 08/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/28/2024
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 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: LUNA SENIOR SERVICES
FACILITY NUMBER: 331881617
VISIT DATE: 08/28/2024
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Utensils and dishware are sufficient for the requested capacity. The refrigerator and stove are in working order. Sharps will be stored in a locked cabinet, available only to authorized individuals.

The following signs were observed to be posted at the home: Theft and Loss Policies, Personal Rights, Resident/Family Councils, and Complaint Information.

LPA observed that the physical plant is clean, in good repair, and to be hazard-free during today’s visit. LPA determined the facility meets the operational requirements for licensure. The Pre-licensing inspection is complete, and this facility has no deficiencies. The facility has satisfied all requirements in accordance with Title 22, California Code of Regulations. An exit interview was conducted, and this report was discussed and provided to applicant, Sahak Hovsepian.
SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Seo Jeon
LICENSING EVALUATOR SIGNATURE:

DATE: 08/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2024
LIC809 (FAS) - (06/04)
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