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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610412
Report Date: 08/09/2023
Date Signed: 08/09/2023 03:10:22 PM

Document Has Been Signed on 08/09/2023 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
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:GRANT SERENITY OF VERDUGO, INC.FACILITY NUMBER:
197610412
ADMINISTRATOR:GEVORKIAN, NVARDFACILITY TYPE:
740
ADDRESS:3214 W. VERDUGO AVETELEPHONE:
(818) 425-6797
CITY:BURBANKSTATE: CAZIP CODE:
91505
CAPACITY: 6CENSUS: 0DATE:
08/09/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:TIME COMPLETED:
03:20 PM
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At 10:00AM Licensing Program Analyst (LPA), Antonia Alvizar conducted an announced Pre-Licensing visit to the above facility and met with Applicant/Licensee, Nvard Gevorkian.

Fire Clearance was approved on 07/10/2023 for a maximum capacity of six (6) residents, of which three (3) Non-Ambulatory and three (3) Bedridden residents. 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 10:20AM, 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. New Fire Extinguishers were dated 07/07/23.

LAUNDRY ROOM: The laundry room is located next to the kitchen divided with a locked door. The washer/dryer appear to be in good condition. Laundry supplies are kept inaccessible when not in use with supervision.

BEDROOMS: There are five (5) 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 10:35AM 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. Water temperature was within regulation.


Continue on LIC809-C

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Antonia Alvizar
LICENSING EVALUATOR SIGNATURE: DATE: 08/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/09/2023
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
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: GRANT SERENITY OF VERDUGO, INC.
FACILITY NUMBER: 197610412
VISIT DATE: 08/09/2023
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COMMON AREAS: The facility maintains a comfortable temperature at 74°F. The living room and dining area appeared clean and were properly furnished. In the living room cabinet there were puzzles, coloring books, crayons, and board games. No obstructions and or tripping hazards throughout the facility.
MEDICATION ROOM: The medication and facility staff/resident files will be kept in a locked office between the living room and restroom.
SMOKE DETECTORS/CARBON MONOXIDE. Dual smoke detectors and carbon monoxide were located in the bedrooms and throughout the facility. At 10:50AM they were tested and observed to be operational. SURROUNDING GROUNDS: The entrance to the home is not gated. 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. The attached garage is kept locked and currently being used for storage with emergency food. LPA discussed the importance of maintaining the care and supervision to meet the needs of clients. There are no bodies of water.


Upon completing an inspection of the physical plant and reviewing a floor plan, LPA Alvizar noted that there were some changes to physical plant that was not identify in the floor plan. Based on LPA's review, the changes made to the floor plan may require approved permits from the Department of Building and Safety.

The issue was discussed with the Administrator, and she indicated that updated floor plan was send to the Centralized Application Bureau (CAB) and they had all required approved permits. During this visit the Licensee representative was able to provide copies of the approved permits and updated floor plan. LPA Alvizar informed the Administrator that the physical plant is meeting pre-licensing requirements. However, LPA need to contact to the Application specialist to ensure that they receive updated floor plan and that the correct sketch was submitted to fire department while requesting a fire clearance.

LPA also will submit the copies of the documents gathered during this visit to CAB to attach to the facility file.

Component III: Upon review of the Licensing records, LPA Alvizar noted that on 02/23/2018 the applicant representative Nvard Gevorkian completed the Component III during Pre-Licensing visit at facility “Grant Serenity Homes Inc #197609351” at which time the applicant was explained how to operate the facility within substantial compliance and had an opportunity to ask questions.


LPA Alvizar spoke with LPM Margaryan over the phone and Component III was waived based on LPA's discussion with the LPM.

Based on inspection and observation, the physical plant is in compliance with Title 22 Regulations at this time. This report will be forwarded to the Centralized Application Bureau (CAB) and the applicant will 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 Nvard Gevorkian.
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Antonia Alvizar
LICENSING EVALUATOR SIGNATURE:

DATE: 08/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2023
LIC809 (FAS) - (06/04)
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