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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609842
Report Date: 09/30/2022
Date Signed: 09/30/2022 10:41:04 AM

Document Has Been Signed on 09/30/2022 10:41 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., 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) 488-9109
CITY:GRANADA HILLSSTATE: CAZIP CODE:
91344
CAPACITY: 6CENSUS: 6DATE:
09/30/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:03 AM
MET WITH:Nick YegeyanTIME COMPLETED:
10:50 AM
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Licensing Program Analyst (LPA), Patrick Shanahan, arrived at the facility and was greeted by facility staff. The administrator was called and arrived a short while later. The LPA explained that the reason for the visit was in order to conduct an infection control annual. The inspection tool was used to complete this annual.

The home has three bedrooms and three bathrooms. The facility staff took the LPA's temperature and asked the covid-19 protocol questions before allowing the LPA into the home. The smoke alarms/ Carbon monoxide detectors were tested and functioned properly. The fire extinguisher was observed in the kitchen and appeared functional.

The facility is currently following their infection control plan. No deficiencies observed. Exit interview conducted and report issued.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Patrick Shanahan
LICENSING EVALUATOR SIGNATURE: DATE: 09/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/30/2022
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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