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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610083
Report Date: 11/04/2023
Date Signed: 11/04/2023 03:47:13 PM

Document Has Been Signed on 11/04/2023 03:47 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: 6DATE:
11/04/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:35 PM
MET WITH:Nazar "Nick" YegeyanTIME COMPLETED:
03:45 PM
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Licensing Program Analyst (LPA) Michael Cava conducted an Annual Required visit and inspection of the facility. LPA met with the administrator, Nazar "Nick" Yegeyan and explained the reason for the visit.

The facility is a one story building. It is located behind the property of the 17177 San Jose Street address (licensed facility). There is no swimming pool or bodies of water on property. The smoke alarms are hardwired. There are carbon monoxide works dual with the smoke alarms. There are two new fire extinguishers. Both fully charged. One fire extinguisher is located at the kitchen, and the other in the hallway.

Kitchen: The kitchen appliances and fixtures were functional. LPA found a sufficient amount of perishable and non-perishable food at the facility; properly stored. Knives were stored in a locked box inside a kitchen drawer.

Bedrooms: There are three (3) bedrooms designated for residents' use. The three bedrooms are shared. Bedrooms were properly furnished with appropriate beddings and linens with sufficient lighting.

Bathrooms: There are two (2) bathrooms. Bathrooms were properly supplied and had functional fixtures. Hot water temperature was measured at 107 degrees Fahrenheit. No cleaning supplies were observed.

Common Areas: These included the living room and dining area. The common areas were properly furnished. The dining room table is large enough to seat up to six residents. Floors were cleaned, maintained and clear of obstruction. The auditory alarms on all exit doors were on and functional at the time of the visit. All exits were clear of obstruction.
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Michael Cava
LICENSING EVALUATOR SIGNATURE: DATE: 11/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/04/2023
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: SAINT MARY'S RESIDENTIAL CARE
FACILITY NUMBER: 197610083
VISIT DATE: 11/04/2023
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Surrounding Grounds: Entry/exits were free of obstruction. The outdoor patio is shared with the front property. There was furniture appropriate for outdoor use. The outdoor area was free of hazards. The back of the home has a locked storage. The laundry area is located in the hallway by the resident rooms. No detergents or cleaning supplies observed. Resident and staff files are maintained in a locked cabinet by the kitchen.

Resident Files: LPA conducted a file review of resident records to insure compliance of licensing forms.

Staff Files: LPA also conducted a file review of staff records to insure forms and training are up to date and compliance with licensing forms.

Medications: Medication and Medication Records are stored in a locked cabinet by the kitchen. Medications were reviewed for proper storage and documentation.

Pursuant to Title 22 Division 6 of the CA Code of Regulations, there were no deficiencies observed during the visit. Exit Interview Conducted and a Copy of the Report Issued.
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Michael Cava
LICENSING EVALUATOR SIGNATURE:

DATE: 11/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2023
LIC809 (FAS) - (06/04)
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