197609731-9-14-2022-31-AS-MCAA-CJ9T77-20220914142817

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609731
Report Date: 09/14/2022
Date Signed: 09/14/2022 02:28:52 PM

Document Has Been Signed on 09/14/2022 02:28 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:	G & A CARE		FACILITY NUMBER:	197609731
ADMINISTRATOR:	KOSOYAN, GRIGOR		FACILITY TYPE:	740
ADDRESS:	16301 NORDHOFF STREET		TELEPHONE:	(323) 314-2996
CITY:	NORTH HILLS	STATE: CA	ZIP CODE:	91343
CAPACITY: 6		CENSUS: 4	DATE:	09/14/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:40 AM
MET WITH:	Grigor Kosoyan		TIME COMPLETED:	02:30 PM

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	Licensing Program Analysts (LPAs) Evelin Rios and Michael Cava conducted an Annual Required visit and inspection of the facility. LPAs met with the administrator, Grigor Kosoyan and explained the reason for the visit. At 11:40am, with the assistance of the administrator, LPAs took a tour of the physical plant. Required postings were observed in the entry area. The smoke alarms and carbon monoxide detectors are dual. They are hardwired and interconnected. The fire extinguisher is located by the front door, next to the kitchen. The charge date is 8/24/2021. Kitchen: The kitchen appliances and fixtures were functional. LPAs found a sufficient amount of perishable and non-perishable food at the facility; properly stored. Knives were stored in a locked drawer in the kitchen. Properly labeled medications were locked in one of the kitchen cabinets. Bedrooms: There were four (4) bedrooms designated for residents' use. All four bedrooms, in use by residents were properly furnished with appropriate beddings and linens with sufficient lighting. Bathrooms: There are two (2) bathrooms designated for residents' use. Bathrooms were properly supplied and had functional fixtures. Hot water temperature was measured at 107.6 degrees Fahrenheit. Common Areas: These included the living room and dining area. The common areas were properly furnished. The auditory alarms on all exit doors were on and functional at the time of the visit.

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Michael Cava
LICENSING EVALUATOR SIGNATURE:	DATE: 09/14/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2022

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., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: G & A CARE	FACILITY NUMBER: 197609731
	VISIT DATE: 09/14/2022

NARRATIVE

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Surrounding Grounds: Entry/exits were free of obstruction. There was furniture appropriate for outdoor
use. There is a swimming pool in the backyard that has a five foot fence installed around its parameters. The gates to enter through the fence were both observed locked and inaccessible for the residents to gain entry. The backyard has a detached unit, utilized as staff quarters. LPAs inspected this to insure no clients were residing there. Administrator stated he lives there. LPAs observed a bed, closet space, and a bathroom in this installation. The outdoor area was free of hazards. The laundry area and detergents are located by the kitchen. Cleaning supplies also stored in the laundry area were kept locked and inaccessible to the residents.

Resident Files: LPA conducted a file review of resident records to insure compliance of licensing forms.

Staff Files: LPA also conducted a file review of staff records to insure forms and training are up to date and compliance with licensing forms.

Medications: Medication and Medication Records were review for proper documentation.

Pursuant to Title 22 Division 6 of the CA Code of Regulations, no deficiencies observed during the visit.

Exit Interview Conducted / Appeal Rights Discussed / A Copy of the Report Issued.

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Michael Cava
LICENSING EVALUATOR SIGNATURE:	DATE: 09/14/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2022

LIC809 (FAS) - (06/04)

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