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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609864
Report Date: 10/02/2024
Date Signed: 10/02/2024 03:50:27 PM

Document Has Been Signed on 10/02/2024 03:50 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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:GRANT SERENITY HOMES OF SF VALLEY, INCFACILITY NUMBER:
197609864
ADMINISTRATOR/
DIRECTOR:		ADJIAN, MARTINFACILITY TYPE:
740
ADDRESS:6928 PEACH AVETELEPHONE:
(818) 425-6797
CITY:VAN NUYSSTATE: CAZIP CODE:
91406
CAPACITY: 6CENSUS: 4DATE:
10/02/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:05 AM
MET WITH:Nvard GevorkianTIME VISIT/
INSPECTION COMPLETED:
02:21 PM
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Licensing Program Analysts (LPA) Sandra arrived at the facility unannounced to conduct a required annual visit at 11:05 a.m. Upon arrival LPA was greeted by staff, and the LPA explained the reason for the visit. Staff contacted the Administrator on the phone to inform them of the visit. The Administrator arrived shortly thereafter.
The LPA and the staff toured the physical plant areas inside and outside to ensure there are no health and safety hazards and the facility is in compliance with Title 22 Regulations.

COMMON AREAS: At the time of the visit, living room and dining room furniture was observed to be in good condition. The facility maintained a comfortable temperature of 76 degrees. Smoke detector(s) and carbon monoxide detector were tested and operational at the time of the visit. The two (2) fire extinguishers were fully charged and were last serviced on 10/19/2023. The LPA observed required postings throughout the common space.

KITCHEN: The kitchen appeared to be clean and the appliances and fixtures functional during the time of visit. The LPA observed a sufficient amount of perishable and at the facility. Sharp objects are stored in a locked cabinet drawer in the kitchen to the right of the stove. No cleaning supplies or toxins are stored under the sink. Non-perishable food pantry was observed to be stocked with sufficient pantry items. The non-perishable emergency supply of food was observed to be stored in the garage area in a locked cabinet.


LAUNDRY ROOM: Laundry room is located to the left of the refrigerator within the kitchen area. It was observed to be locked and inaccessible to residents in care at the time of the visit. LPA observed cleaning supplies and other toxins stored in this location. It was observed to be inaccessible to residents in care.
BEDROOMS: The residents’ bedrooms were properly furnished with a bed, nightstand, and sufficient lighting for each resident. The bedrooms had appropriate and adequate bedding and linens such as sheets, pillowcases, mattress pads, and blankets.
Continues on LIC 809C...
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Sandra Urena
LICENSING EVALUATOR SIGNATURE: DATE: 10/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/02/2024
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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: GRANT SERENITY HOMES OF SF VALLEY, INC
FACILITY NUMBER: 197609864
VISIT DATE: 10/02/2024
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BATHROOM: The facility has one bathroom for residents and staff. The LPA observed bathroom to have grab bars and non-skid mats. The hot water was measured in each bathroom between 110 - 113 degrees Fahrenheit.

OUTDOOR AREA: The backyard has a shaded outdoor area equipped with furniture for client use. No bodies of water were observed. The LPA observed an additional building in the far end of the property behind the garage. Next to the detached garage the LPA observed an empty pool that was gated and inaccessible to residents in care. The outdoor area behind the detached garage is inaccessible to residents in care at this time. Passageways were free and clear from obstruction. LPA observed shaded seating area with appropriate outdoor furniture in the front of the facility as well.

RECORDS: Records review began at 1:15 p.m. Residents’ records were reviewed for, but not limited to care plans, medical records, admissions agreement, consent forms. All records were in order. Personnel records were reviewed for, but not limited to health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All files were in order.

MEDICATIONS: Medications review began at 12:25 p.m.; medications are centrally stored and locked in a cabinet and small refrigerator in the office area; medications are labeled and were checked for expiration dates. The LPA observed that the medications are not being documented on the Centrally Stored Medications and Destruction Record form (LIC 622), however the medications are being documented in facility created form. The Administrator understood that the facility must document the medications in the required Department’s form (LIC 622). The Administrator will submit the completed forms (LIC 622) for four residents to the LPA by 10/07/2024. The LPA was able to conduct a random audit of the bubble packet medications, and there were no errors observed during the medication review.

INFECTION CONTROL: The facility has an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19.

The LPA reviewed the following documents:- LIC500 Personnel Report &LIC9020 Client Roster, Certificate of Liability

Exit interview conducted. A copy of the report was issued.

SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Sandra Urena
LICENSING EVALUATOR SIGNATURE:

DATE: 10/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/02/2024
LIC809 (FAS) - (06/04)
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