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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610337
Report Date: 03/03/2023
Date Signed: 03/03/2023 11:40:26 AM

Document Has Been Signed on 03/03/2023 11:40 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:NH CARE, LLCFACILITY NUMBER:
197610337
ADMINISTRATOR:KOSOYAN, GRIGORFACILITY TYPE:
740
ADDRESS:15757 SEPTO STREETTELEPHONE:
(818) 919-9181
CITY:NORTH HILLSSTATE: CAZIP CODE:
91343
CAPACITY: 6CENSUS: 0DATE:
03/03/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Grigor KosoyanTIME COMPLETED:
11:45 AM
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On 3/3/2023, Licensing Program Analyst (LPA) Melissa Ruiz arrived at the facility to conduct an announced Pre-licensing inspection. Upon arrival LPA met with applicant Grigor Kosoyan. The facility will be licensed as a Residential Care Facility for the Elderly. Facility is a single-story house with three (3) bedrooms and two (2) bathrooms. Facility has been approved for a capacity for six (6) clients.

The physical plant was toured inside and out at 10:10 a.m. and LPA observed the following:

Common Area: LPA observed the living room and furniture to be clean and in good repair. LPA observed the dining area to be clean and in good repair. The air conditioner is operational. No firearms observed or will be maintained on the premises. The smoke alarm and carbon monoxide detector are dual functioning and hard wired throughout the facility. There are various fire extinguishers which were observed to be fully charged. Facility maintains an operational telephone.

Kitchen Area: LPA observed the kitchen area to be in good repair and sanitary. A cabinet with a lock will be used to keep sharps locked and inaccessible to residents in care. Medication will also be centrally stored and locked in a kitchen cabinet. Trash containers have tight-fitting lids.

Bedrooms: Facility has three (3) bedrooms, two (2). Bedrooms will be shared. and All bedrooms were toured and were observed with the appropriate furniture and bedding and sufficient lighting was observed.

Bathrooms: Facility has two (2) bathrooms one of which will be for staff use. Bathrooms were toured and were observed to be clean. LPA observed sufficient towels and wash cloths for residents. Trash cans with lids were observed.

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Melissa Ruiz
LICENSING EVALUATOR SIGNATURE: DATE: 03/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/03/2023
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: NH CARE, LLC
FACILITY NUMBER: 197610337
VISIT DATE: 03/03/2023
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Outside: LPA observed a shaded area for residents. Patio furniture was observed with a shaded area. There are no bodies of water. LPA observed a detached garage.

Administrative: LPA discussed preplacement staffing, training, customer service, inspection authority, reporting requirements (mandated reporter), records, citations, criminal record clearance, civil penalties, activities, and expectations to follow all rules and regulations. Component III was waived; applicant is already licensed at another facility.

This report will be sent to Centralized Application Bureau (CAB). You will be notified by the CAB Analyst when the 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. Report has been signed and delivered. Exit interview conducted.

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Melissa Ruiz
LICENSING EVALUATOR SIGNATURE:

DATE: 03/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2023
LIC809 (FAS) - (06/04)
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