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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610083
Report Date: 09/24/2021
Date Signed: 09/24/2021 01:13:02 PM

Document Has Been Signed on 09/24/2021 01:13 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 MARY'S RESIDENTIAL CAREFACILITY NUMBER:
197610083
ADMINISTRATOR:YEGEYAN, NAZARFACILITY TYPE:
740
ADDRESS:17177 1/2 SAN JOSE STREETTELEPHONE:
(818) 403-1803
CITY:GRANADA HILLSSTATE: CAZIP CODE:
91344
CAPACITY: 6CENSUS: 4DATE:
09/24/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Nazar YegeyanTIME COMPLETED:
01:20 PM
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Licensing Program Analyst (LPA), Patrick Shanahan, Arrived at the home in order to conduct a required 1 year annual inspection of this home. The LPA was greeted by facility staff and explained the reason for the visit. The administrator arrived a short while later.

At 11:15 AM, upon entry, LPA observed that staff were not wearing masks in the home and the covid-19 questions were not asked to the LPA. LPA reminded the staff about masks and checking the visitors temperatures and the staff apologized and proceeded to follow their mitigation plan protocol.

LPA was able to briefly tour the home and no health and safety concerns were observed during the visit. There appeared to be a sufficient amount of perishable and non-perishable foods at the home, properly stored. The home appeared clean and sanitary during todays visit.

Exit interview conducted and report issued.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Patrick Shanahan
LICENSING EVALUATOR SIGNATURE: DATE: 09/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/24/2021
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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