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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195850293
Report Date: 02/28/2023
Date Signed: 02/28/2023 01:32:12 PM

Document Has Been Signed on 02/28/2023 01:32 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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:NORTH RESIDENTIAL CARE INCFACILITY NUMBER:
195850293
ADMINISTRATOR:DURGARYAN, REBEKAFACILITY TYPE:
740
ADDRESS:7846 AGNES AVETELEPHONE:
(818) 404-0290
CITY:NORTH HOLLYWOODSTATE: CAZIP CODE:
91605
CAPACITY: 6CENSUS: 6DATE:
02/28/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
11:25 AM
MET WITH:Rebeka DurgaryanTIME COMPLETED:
01:40 PM
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Licensing Program Analyst (LPA), Sandra Urena arrived at the facility at 11:25 a.m., and met with Applicant Rebeka Durgaryan. This is an application for a Change of Ownership(CHOW). Facility has capacity for a total of six (6) non-ambulatory residents. Fire Clearance was approved on 01/20/2023 for six (6) non-ambulatory residents only.

The facility has five bedrooms and three bathrooms. Three bedrooms will be shared rooms for residents. One bedroom will be used for an office and one bedroom will be used as a staff room.

At 11:45 a.m. the LPA, and the Applicant toured the physical plant areas inside and outside to ensure there are no health and safety hazards, and facility is in compliance with Title 22 Regulations.

KITCHEN: A seven-day supply of non-perishable food was available. The supply of dishes is adequate.
Appliances in the kitchen were clean and all appeared functional. House cleaning supplies will be stored in locked cabinet in the laundry room. At 12:07 p.m. the hot water temperature was recorded at 112.2 Fahrenheit degrees. Knives are locked in a safety box found on top of the kitchen counter.

BEDROOMS: Facility has five (5) bedrooms total. Three (3) bedrooms will be utilized for shared resident use. One bedroom will be used for an office, and one bedroom will be used as a staff room. Lighting in the rooms appeared adequate. All bedrooms had adequate closet and drawer space for clothing and personal belongings. Bedrooms are equipped with televisions. At 12:12 p.m. the LPA and Applicant observed one television in bedroom #1, which sits on top of a cabinet drawer, and another television mounted on the wall. The TV on top of the cabinet drawer needs to be secured to wall or cabinet drawer.
Continues on LIC 809C...
SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Sandra Urena
LICENSING EVALUATOR SIGNATURE: DATE: 02/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/28/2023
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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: NORTH RESIDENTIAL CARE INC
FACILITY NUMBER: 195850293
VISIT DATE: 02/28/2023
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BATHROOMS: The facility has three bathrooms. Bathrooms are fully stocked with paper towels, and liquid hand soap. The showers have non-skid surface mats. Hot water temperatures were recorded in Fahrenheit degrees as follows: 109.5 degrees for bathroom #1 at 12:10 p.m., 108.1 degrees for bathroom #2 at 12:15 p.m., and 108.9 degrees for bathroom #3 at 12:17 p.m. Hand washing signs were visible and posted.

COMMON AREAS: The common areas were appropriately furnished, and the lighting was adequate.
A television is found in the living room area.

OUTDOOR AREA: The exterior passageways were clean, and clear of any obstructions. The side patio is furnished with outdoor furniture for residents’ use, and shade is available. The building has a central entrance for visitors. Fire emergency gates are clear of obstructions.

-The first aid supplies were complete, including a thermometer. The first aid kit is located at the entrance on a side table.
-Medications are stored in locked cabinet located found in between the kitchen and common areas.
-Residents, and staff records are stored and locked in file cabinet located in the Office Room.
-The facility’s smoke/carbon monoxide alarm systems are hard wired. All rooms were tested, and all
smoke/carbon monoxide alarm systems were in operating condition. Three fire extinguishers are properly charged, and mounted on the wall in the kitchen area, common areas and hallway by bedroom #1.
-The laundry area is located next to the kitchen, washer was in the process of being repaired. The supply of linens is sufficient to permit changing weekly or more often as needed to ensure use of linens at all times.
-An operating telephone is available for resident use. And is located in the living room area.
-Infection control, and other posters are posted in the living room area.
-At 12:24 p.m. the LPA and the Applicant observed that the Emergency Exiting Plan needs to be updated to reflect current staff.
-At 12:29 p.m. the LPA and Applicant observed that activity supplies were not present, and neither an activity program plan.

Continues on LIC 809C...
SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Sandra Urena
LICENSING EVALUATOR SIGNATURE:

DATE: 02/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/28/2023
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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: NORTH RESIDENTIAL CARE INC
FACILITY NUMBER: 195850293
VISIT DATE: 02/28/2023
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-Applicant stated they will be contracting with a transportation company which will be utilized to transport residents.

Pre-Licensing is incomplete with deficiencies to be resolved. During the inspection, the LPA, and Applicant
observed the following corrections needed, prior to being licensed:

1. Emergency Exiting Plan needs to be updated to reflect current staff.
2. Activity supplies were not present, or an activity program plan.
3. Applicant stated that the TV in Bedroom #1 will be removed.
4. Applicant will provide copy of the invoice for washer fixed.

The applicant completed Component III Orientation.

This report will be sent to the Centralized Application Bureau (CAB). You will be notified by the CAB Analyst
when your license has been approved. You are not allowed to begin operating until you have been notified
that your license has been approved by the CAB Analyst. Failure to comply could affect approval of your
license.

Exit interview was conducted and reviewed with applicant Rebeka Durgaryan. A copy of the report was
issued.
SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Sandra Urena
LICENSING EVALUATOR SIGNATURE:

DATE: 02/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/28/2023
LIC809 (FAS) - (06/04)
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