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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610412
Report Date: 10/25/2023
Date Signed: 10/25/2023 06:41:34 PM

Document Has Been Signed on 10/25/2023 06:41 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: 5DATE:
10/25/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
04:15 PM
MET WITH:AdministratorTIME COMPLETED:
06:50 PM
NARRATIVE
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Licensing Program Analyst(LPA) Antonia Alvizar met with the Administrator, Nvard Gevorkian and made an initial complaint #31-AS-20231024151628 visit to this facility. This Case Management has nothing to do with complaint visit.

During Complaint Investigation, LPA Alvizar discovered the following Full-time Staff (S1) and (S2) have been present without a Criminal Background Clearance and Association to this facility. S1 and S2 are married and stated their first day of work was 09/10/2023. LPA request/received staff S1 and S2 California Identification Card.

LPA verified using Guardian Background System Check, staff S1 and S2 names did not appeared on facility roster.

S1- Vera Romanova DOB: 11/07/1997
S2- Nikolai Romanov DOB: 05/02/1989

S1 and S2 were asked to leave the facility and do not return until Criminal Background Clearance and Associated to this facility.

A citation and civil penalty were issued. Copy of this report was provide to Administrator Gevorkian
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Antonia Alvizar
LICENSING EVALUATOR SIGNATURE: DATE: 10/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/25/2023
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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Document Has Been Signed on 10/25/2023 06:41 PM - It Cannot Be Edited


Created By: Antonia Alvizar On 10/25/2023 at 05:22 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: GRANT SERENITY OF VERDUGO, INC.
FACILITY NUMBER: 197610412

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/25/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/26/2023
Section Cited
CCR
87355(b)(2)

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All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working... in a licensed facility: (2)Request a transfer of a criminal record clearance as specified in Section 87355(c)... This requirement is not met as evidence by:
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Administrator has agreed to email the completed criminal background clearance
and associate Staff S1 and S2 to facility by POC due date.

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Based on interview and review of Guardian Background System Check facility Staff S1 and S2 are not criminal background clearanced and association to this facility. No documentation has been submitted to Community Care Licensing. This poses a potential risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Naira Margaryan
LICENSING EVALUATOR NAME:Antonia Alvizar
LICENSING EVALUATOR SIGNATURE:
DATE: 10/25/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/25/2023


LIC809 (FAS) - (06/04)
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