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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610323
Report Date: 07/26/2023
Date Signed: 07/26/2023 12:55:56 PM

Document Has Been Signed on 07/26/2023 12:55 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:CARING LOVE BOARDING CAREFACILITY NUMBER:
197610323
ADMINISTRATOR:KIRAKOSYAN, SEROZHFACILITY TYPE:
740
ADDRESS:5902 SHIRLEY AVETELEPHONE:
(818) 793-4777
CITY:TARZANASTATE: CAZIP CODE:
91356
CAPACITY: 6CENSUS: 0DATE:
07/26/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Khachatur Grigoryan, OwnerTIME COMPLETED:
01:20 PM
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At 9:30am Licensing Program Analyst (LPA), Angela Panushkina conducted an announced Pre-Licensing visit to the above facility and met with Applicant/Licensee, Khachatur Grigoryan.

Fire Clearance was approved on 04/05/2023 for a maximum capacity of six (6) residents, of which two (2) Ambulatory, three (3) Non-Ambulatory and one (1) bedridden residents. Hospice waiver for six (6) residents was approved on 06/28/23.

The purpose of today’s visit is to inspect the facility to ensure that the facility is in compliance with rules and regulations under California Code of Regulations, Title 22, Division 6. The facility is a single-story building. Today's site visit consisted of LPA touring the physical plant inside and outside and observed the following:

KITCHEN: The facility has a Kitchen area that is equipped with a refrigerator, microwave oven and sink. At 10:00am, LPA observed adequate supplies of perishable and nonperishable food and dining ware to accommodate a maximum capacity of six (6). All knives and sharps are observed to be locked in a kitchen cabinet and inaccessible to residents. Fire Extinguisher was last purchased on 04/05/23.


BEDROOMS: There are three (3) bedrooms designated for client use. All bedrooms are furnished with beds, dressers and required bedding and linen. The bedrooms have sufficient closet space and have sufficient lighting. Auditory alarms were tested and observed to be operational.

BATHROOMS: At 10:25am LPA observed all bathrooms are clean and in good repair. Properly supplied with toilet papers, soap and paper towels. LPA observed appropriate grab bar and had non-skid mat.

COMMON AREAS: The facility maintains a comfortable temperature at 72°F. The living room and dining area
Continue on LIC809-C
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Angela Panushkina
LICENSING EVALUATOR SIGNATURE: DATE: 07/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/26/2023
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: CARING LOVE BOARDING CARE
FACILITY NUMBER: 197610323
VISIT DATE: 07/26/2023
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appeared clean and were properly furnished. No obstructions and or tripping hazards throughout the facility.

MEDICATION ROOM: The medication and facility staff/resident files will be kept in a locked cabinet located kitchen cabinet.

SMOKE DETECTORS/CARBON MONOXIDE. Smoke detectors were located throughout the facility, and carbon monoxide was located in a hallway, by the bathroom. At 10:30am they were tested and observed to be operational.


LAUNDRY ROOM: The laundry room is located outside by the patio. The washer/dryer appear to be in good condition. Laundry supplies are kept inaccessible when not in use with supervision.

SURROUNDING GROUNDS: The entrance to the home is gated and requires for guest to be announced. In the back of the facility has sufficient yard space. LPA observed appropriate outdoor furniture, with a covered shaded area for clients. The backyard is fenced. There is an empty lot in a back yard that might be separated with a different address in a future. The attached garage is kept locked. The garage is detached and currently being used for storage. LPA discussed the importance of maintaining the care and supervision to meet the needs of clients. There are no bodies of water.

Component III was conducted with the Administrator.

Facility is in compliance with Title 22 Regulations at this time. This report will be forwarded to the Centralized Application Bureau (CAB) and be notified by the CAB Analyst when your license has been approved.

Exit interview was conducted and with a copy of this report was provided to the Applicant/Administrator.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Angela Panushkina
LICENSING EVALUATOR SIGNATURE:

DATE: 07/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2023
LIC809 (FAS) - (06/04)
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