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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610277
Report Date: 10/14/2022
Date Signed: 10/14/2022 11:30:52 AM

Document Has Been Signed on 10/14/2022 11:30 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:NORTH HILLS VILLAFACILITY NUMBER:
197610277
ADMINISTRATOR:TER-ARSENYAN, ARSENFACILITY TYPE:
740
ADDRESS:16437 PARTHENIA STTELEPHONE:
(424) 444-9998
CITY:NORTH HILLSSTATE: CAZIP CODE:
91344
CAPACITY: 6CENSUS: 0DATE:
10/14/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:14 AM
MET WITH:Arsen Ter-Arsenyan/ AdministratorTIME COMPLETED:
11:45 AM
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Licensing Program Analyst (LPA) Patrick Shanahan, arrived at the facility in order to conduct a pre-licensing visit. The LPA was greeted by the facility administrator and was able to tour the home inside and out. This is a new facility pre licensing and there were no residents present during the visit. The inspection tool was used to conduct this visit.

The home has 3 bedrooms and 2 bathrooms for residents use. There is also one staff room, 2 storage rooms and one office at the facility. The smoke alarms and carbon monoxide detectors were tested and functioned properly. A functional fire extinguisher was observed in the kitchen.

No deficiencies were observed during today's visit.

Component III was conducted during the visit.

This report will be sent to the Centralized Application Bureau (CAB) You will be notified by the CAB Analyst when your license has been approved. You are not allowed to begin operating until you have been notified that your license has been approved by the CAB analyst. Failure to comply could affect approval of your license.


Exit interview conducted and report issued.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Patrick Shanahan
LICENSING EVALUATOR SIGNATURE: DATE: 10/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/14/2022
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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