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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195850293
Report Date: 04/03/2023
Date Signed: 04/04/2023 07:55:33 AM

Document Has Been Signed on 04/04/2023 07:55 AM - 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: 5DATE:
04/03/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Rebeka DurgaryanTIME COMPLETED:
10:45 AM
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Licensing Program Analyst (LPA), Sandra Urena conducted subsequent visit to finalized the prelicensing visit, arrived at the facility at 9:45 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.

On 02/28/2023, conducted an initial pre-licensing visit. 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.

Pre-Licensing is complete with deficiencies resolved. During the inspection, the LPA, and Applicant
observed the following corrections resolved:

1. Emergency Exiting Plan was updated to reflect current staff.
2. Activity supplies were present with an activity program plan.

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: 04/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/03/2023
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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