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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609749
Report Date: 04/19/2022
Date Signed: 04/19/2022 12:29:46 PM

Document Has Been Signed on 04/19/2022 12:29 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:ENCINO GARDENSFACILITY NUMBER:
197609749
ADMINISTRATOR:ARUTUNYAN, ALEXFACILITY TYPE:
740
ADDRESS:4930 NOELINE AVETELEPHONE:
(818) 983-5598
CITY:ENCINOSTATE: CAZIP CODE:
91436
CAPACITY: 6CENSUS: 6DATE:
04/19/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:43 AM
MET WITH:Zoey GevorkianTIME COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA) Abeye Duguma met with Zoey Gevorkian for a One (1) Year Required - Infection Control visit for this facility. LPA explained the reason for the visit. A tour of the physical plant was conducted at 9:45am and the following was noted:
There is one entrance being utilized at the facility, there are required posters posted at the main door. Screening area is located immediately upon entrance. Sign in sheet, infrared thermometer, hand sanitizer, gloves and masks are available. LPA was screened upon entry. All staff were observed to be wearing masks upon entrance and during the visit. Signs to wear masks and other COVID 19 prevention protocol signs were posted outside the doors. The facility is fire cleared for six (06) non-ambulatory of which one (01) may be bedridden and a hospice waiver for six (06). The facility is currently occupying five (05) residents. Hand washing, coughing etiquette, physical distancing and other necessary signs were posted in the bathroom and all over the facility. The facility has sufficient stock of PPE. The facility has six (06) bedrooms; all bedrooms were properly furnished and supplied with appropriate bedding and linens. Rooms observed to have bedspreads, sheets, pillowcase, mattress pad, and blankets. There were sufficient linens observed and available. There are four (04) bathrooms; all were clean, with soap, towels, grab bars, and non-skid mats. The facility has outdoor furniture with a covered shaded area for residents and visitors. The facility has a gated and locked swimming pool. The laundry detergents, cleaning agents and other toxins are stored in a locked kitchen cabinet. Food Service/Kitchen area was sufficiently stocked with at least two (2) days perishable and seven (7) days non-perishable food. Frozen foods are properly wrapped and stored appropriately. Food storage and preparation areas are clean and inaccessible to pests.
Knives and sharps are observed to be locked in a cabinet under the sink, inaccessible to residents. Living/common and dining room furniture were also checked. The living/common room is neat and clean along with the dining room. The facility maintains a comfortable temperature at 70°F. The smoke and carbon monoxide detectors are hardwired, interconnected and observed to be operational.
(continued on LIC 809-C)
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Abeye Duguma
LICENSING EVALUATOR SIGNATURE: DATE: 04/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/19/2022
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: ENCINO GARDENS
FACILITY NUMBER: 197609749
VISIT DATE: 04/19/2022
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Fire extinguisher is located in the bedroom, observed to be full and last inspected on 12/22/2021. Staff rooms were observed to be locked and located near the dining area. No medications are observed in the staff room. The residents' rooms are adequately furnished with appropriate furniture and lighting system. Hallways/passageways are well lit. Residents have enough personal hygiene product provided by the licensee. The bathroom was checked for cleanliness and proper operations. The hot water temperature was measured at 116.8°F. Towels and washcloths are not shared. LPA observed medication to be locked and inaccessible to residents, located in the kitchen cabinet. There is a complete first aid kit located near the foyer.

Exit interview conducted. Copy of this report issued.
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Abeye Duguma
LICENSING EVALUATOR SIGNATURE:

DATE: 04/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/19/2022
LIC809 (FAS) - (06/04)
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