<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610412
Report Date: 12/01/2023
Date Signed: 12/01/2023 03:15:06 PM

Document Has Been Signed on 12/01/2023 03:15 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: 3DATE:
12/01/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:25 PM
MET WITH:TIME COMPLETED:
03:30 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst(LPA) Antonia Alvizar met with the Administrator, Nvard Gevorkian and made a subsequent 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 Part-Time Staff (S1) and (S2) have been present without a Criminal Background Clearance or Transfer and Association to this facility. S1 job title is House Manager, first day of work was 10/01/2023. S2 job title is Cleaner and today was the first day at work. LPA request/received S1 California Driver License. LPA request S2 identification, S2 indicated that did not have any identification on her at the time of this visit. S2 provided LPA with date of birth, first and last name. Administrator confirm that was S2 identification information. Administrator indicated that S2 is contracted by Maybins Cleaning agency.

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

S1- Ruzanna Sukiassyan DOB: 02/21/1961
S2 - Alex Garcia DOB: 02/25/1986


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: 12/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/01/2023
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
Document Has Been Signed on 12/01/2023 03:15 PM - It Cannot Be Edited


Created By: Antonia Alvizar On 12/01/2023 at 01:38 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: 12/01/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/01/2023
Section Cited
CCR
87355(b)(2)

1
2
3
4
5
6
7
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:
1
2
3
4
5
6
7
Administrator has completed Criminal Background Clearance or Transfer & Associated S1 to facility. Administrator provided documentation to LPA dated 12/01/2023. POC has been cleared during today's visit. S2 exit the facility with administrator and will not return.
8
9
10
11
12
13
14
Based on interview and review of Guardian Background System staff S1&S2 are not Criminal Background Clearanced or Transfer & Associated to this facility. No documentation has been submitted to CCLD. This poses a potential risk to residents in care.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: 12/01/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/01/2023


LIC809 (FAS) - (06/04)
Page: 2 of 2