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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107206861
Report Date: 07/07/2021
Date Signed: 07/30/2021 03:42:46 PM

Document Has Been Signed on 07/30/2021 03:42 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, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:BELMAR VILLAFACILITY NUMBER:
107206861
ADMINISTRATOR:HRIPSIME MAKARYANFACILITY TYPE:
740
ADDRESS:2020 NORTH WEBER AVENUETELEPHONE:
(559) 486-5977
CITY:FRESNOSTATE: CAZIP CODE:
93705
CAPACITY: 100CENSUS: 62DATE:
07/07/2021
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
02:47 PM
MET WITH:Hripsime "Kristina" MakaryanTIME COMPLETED:
04:55 PM
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Licensing Program Analyst (LPA) Katie Brown arrived unannounced to conduct a Health and Safety Case Management visit. LPA was greeted by Administrator Hripsime "Kristina" Makaryan who was covering the front desk. LPA introduced self and explained the purpose of the visit.

Administrator and LPA toured the facility inside and out. Required postings were observed. LPA observed staff wearing face coverings and hand sanitizer throughout the facility. LPA verified staffing, food supply, PPE, disinfecting products and paper goods.

Administrator and LPA reviewed and incident involving R1 that occurred on 7/6/21. Special Incident Report (SIR) will be faxed to CCL. Two (2) additional incidents were reviewed that occurred on 7/3/21. SIRs were received by CCL 7/5/21. The incidents that occurred resulted in 911 being called by the facility.

LPA requested a current resident roster as well as staff schedule. These were provided by the Administrator.
LPA emailed Administrator LIC. 808. Administrator agrees to submit a Mitigation Plan no later then 7/14/2021.


No deficiencies cited during this visit. An exit interview was conducted with Administrator and a copy of the report was provided.
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Katie Brown
LICENSING EVALUATOR SIGNATURE: DATE: 07/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/07/2021
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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