<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609508
Report Date: 10/07/2021
Date Signed: 10/07/2021 08:59:44 PM

Document Has Been Signed on 10/07/2021 08:59 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., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:MOUNTAIN VILLAFACILITY NUMBER:
197609508
ADMINISTRATOR:NARINE SARYANFACILITY TYPE:
740
ADDRESS:1845 W. MOUNTAIN STREETTELEPHONE:
(818) 945-5644
CITY:GLENDALESTATE: CAZIP CODE:
91201
CAPACITY: 6CENSUS: 5DATE:
10/07/2021
TYPE OF VISIT:CollateralUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Narine SaryanTIME COMPLETED:
09:40 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
An unannounced Collateral visit was conducted to this facility by Licensing Program Analyst (LPA) Yelena Avetisyan. Upon arrival LPA met with Licensee/Administrator Narine Saryan. This visit is being conducted to confirm information submitted to the department related to complaint control # 31-AS-20210105081240

On 10-4-2021 LPA Avetisyan was notified that resident 1 (R1) who was living in an Unlicensed Care facility was admitted to this facility. The purpose of this visit is to confirm the information provided.

During this visit LPA conducted a brief tour of the facility, spoke with the Resident 1 (R1) and confirmed the date he was admitted to this facility.

Exit interview conducted and copy of report emailed to the operator.
SUPERVISORS NAME: Jill Nakata
LICENSING EVALUATOR NAME: Yelena Avetisyan
LICENSING EVALUATOR SIGNATURE: DATE: 10/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/07/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1