<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610222
Report Date: 05/13/2023
Date Signed: 05/13/2023 03:10:29 PM

Document Has Been Signed on 05/13/2023 03:10 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:KINGSBURY STREET HOME, INC.FACILITY NUMBER:
197610222
ADMINISTRATOR:SARGSIAN, HARUTFACILITY TYPE:
740
ADDRESS:16457 KINGSBURY STREETTELEPHONE:
(818) 519-8080
CITY:GRANADA HILLSSTATE: CAZIP CODE:
91344
CAPACITY: 6CENSUS: 0DATE:
05/13/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Johnny SarkisyanTIME COMPLETED:
03:30 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Michael Cava conducted an Annual Required visit and inspection of the facility. LPA met with the administrator, Johnny Sarkisyan and explained the reason for the visit.

At approximately 12:30pm, with the assistance of the administrator, LPA took a tour of the physical plant. Required postings were observed in the entry area. The smoke alarms and carbon monoxide detectors are dual, hardwired and interconnected. The fire extinguisher is located in the kitchen. It was just purchased on 01/09/23.

Kitchen: The kitchen appliances and fixtures were functional. Currently there are no residents in the home, but there was a sufficient amount of non-perishable food at the facility; properly stored. Knives were stored in a locked drawer in the kitchen.

Bedrooms: There were six (6) bedrooms designated for residents' use. All six bedrooms are for private use. All six bedrooms are properly furnished with appropriate beddings and linens with sufficient lighting.

Bathrooms: There are three (3) bathrooms designated for residents' use. All bathrooms were properly supplied and had functional fixtures. Hot water temperature was measured at 108 degrees Fahrenheit. Bathrooms were clear of any cleaning supplies and toxins.

Common Areas: These included the living room and dining area. The common areas were properly furnished.
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Michael Cava
LICENSING EVALUATOR SIGNATURE: DATE: 05/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/13/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
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: KINGSBURY STREET HOME, INC.
FACILITY NUMBER: 197610222
VISIT DATE: 05/13/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Surrounding Grounds: Entry/exits were free of obstruction. There was furniture appropriate for outdoor
use. The outdoor area was free of hazards. The laundry area is located by the kitchen. There is a staff office located at the corner of the living room area.

Resident Files: Currently there are no residents in the home.

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

Medications: Medications will be stored and locked in a closet near the living room.

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: 05/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2