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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195850350
Report Date: 04/26/2023
Date Signed: 04/26/2023 10:36:53 AM

Document Has Been Signed on 04/26/2023 10:36 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:LA SENIOR HOMEFACILITY NUMBER:
195850350
ADMINISTRATOR:SPRY, NAIRAFACILITY TYPE:
740
ADDRESS:7825 SIMPSON AVENUETELEPHONE:
(818) 299-7501
CITY:NORTH HOLLYWOODSTATE: CAZIP CODE:
91605
CAPACITY: 5CENSUS: 0DATE:
04/26/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Naira Spry and Tigran GevorgyanTIME COMPLETED:
10:05 AM
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Licensing Program Analyst (LPA), Sandra Urena, conducted a subsequent pre-licensing visit at 9:25 a.m. The LPA met with Administrator Naira Spry, and applicant Tigran Gevorgyan. The LPA, and applicants gained access to the detached second dwelling, and the detached storage unit. The dwelling appeared to be unoccupied, and the locked storage units were free of any hazardous materials.

On 04/24/2023, the initial pre-licensing visit was conducted by Licensing Program Analyst (LPA), Sandra Urena. The LPA arrived at the facility at 9:45 a.m., and met with the Administrator Naira Spry, and applicant Tigran Gevorgyan. This is a new application for Residential Care Facility for the Elderly (RCFE) with a capacity for five (5) residents. Four(4) non-ambulatory residents, and one(1) bedridden resident. The facility was cleared by the Lo Angeles Fire Department to have the bedridden resident in bedroom # three(3). The facility is a one story dwelling, three bedrooms, and two bathrooms, with one detached storage unit, and a detached second dwelling in the back, which is not leased to the applicant at the time of the pre-licensing visit.
The following deficiencies were corrected:
1. Sliding Door for bedroom three (3) was leveled, and positioned at the level where wheelchairs and walkers can pass through safely.
2. LPA conducted inspection of the detached dwelling in the back of the facility, and the detached storage units. 3. Added bed to bedroom one (1).
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 with Naira Spry and Tigran Gevorgyan. A copy of the report was issued.

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Sandra Urena
LICENSING EVALUATOR SIGNATURE: DATE: 04/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/26/2023
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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