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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195850176
Report Date: 07/26/2021
Date Signed: 07/26/2021 02:45:42 PM

Document Has Been Signed on 07/26/2021 02:45 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, 744 P STREET, MS 9-14-8201
SACRAMENTO, CA 95814
FACILITY NAME:NOHO ASSISTED LIVING, INCFACILITY NUMBER:
195850176
ADMINISTRATOR:AYVAZYAN, ZHIRAYRFACILITY TYPE:
740
ADDRESS:6331 SIMPSON AVETELEPHONE:
(818) 404-0550
CITY:NORTH HOLLYWOODSTATE: CAZIP CODE:
91606
CAPACITY: 6CENSUS: DATE:
07/26/2021
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Zhirayr Ayvazyan & Arpine MkrtchyanTIME COMPLETED:
02:30 PM
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Facility Type: RCFE
Application Type: Initial
Capacity: 6
Census (if any clients in care): Zero
Method: Telephone call with CAB
COMP II Participants: Arpine Mkrtchyan, licensee / Zhirayr Ayvazyan, Administrator

Applicant/administrator participated in COMP II via telephone call with the analyst at CAB. Identification of the applicant and administrator was verified by photo ID. During COMP II, applicant and administrator confirmed the understanding of Title 22. Component II was successfully completed. Applicant and administrator have been advised to transmit a signed LIC 809 with copy of photo ID to CAB.
SUPERVISORS NAME: Julia Kim
LICENSING EVALUATOR NAME: Dianne Ramos
LICENSING EVALUATOR SIGNATURE: DATE: 07/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/26/2021
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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