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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609842
Report Date: 09/09/2021
Date Signed: 09/13/2021 01:45:31 PM

Document Has Been Signed on 09/13/2021 01:45 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:SAINT NICK ASSISTED LIVINGFACILITY NUMBER:
197609842
ADMINISTRATOR:YEGEYAN, MARYFACILITY TYPE:
740
ADDRESS:17177 SAN JOSE STREETTELEPHONE:
(818) 403-1803
CITY:GRANADA HILLSSTATE: CAZIP CODE:
91344
CAPACITY: 6CENSUS: 5DATE:
09/09/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Nick YegeyanTIME COMPLETED:
03:28 PM
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Licensing Program Analyst (LPA) Angelica Arambulo conducted an unannounced required annual visit. LPA was greeted by Nick Yegeyan. The current census is 5 resident. Purpose of the visit was given to Nick, and LPA was screened at the door for temperature and questioned about any Covid symptoms. The facility has visitation signs on the front door along with Covid 19 information.

The sample questionaire for screening needed o be updated along with the Covid signs. The mitigation plan was hanging on the board along with required signs such as emergency disaster plan, staff schedule, theft and loss plan. All bathrooms had hand washing signs and each resident appeared well groomed. Upon LPA review of the hard copy mitigation plan there was no approved signature. Nick stated that he did get the approval and just could not find the one in his email. The back house to this lot is also a licensed facility with an approved plan. He showed LPA their approved mitigation plan. Nick and his sister are administrators.

LPA conducted a tour of the facility to check on residents. The LPA will have to check back at the office to see if an approved mitigation plan is on file. He did have the one for ST Marys which is the back house. They were approved together. Upon checking the administrators email it was discovered we did not have the correct email. LPA will follow through and update the records.
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Angelica Arambulo
LICENSING EVALUATOR SIGNATURE: DATE: 09/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/09/2021
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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