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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610412
Report Date: 09/27/2024
Date Signed: 10/16/2024 03:52:02 PM

Document Has Been Signed on 10/16/2024 03:52 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.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:GRANT SERENITY OF VERDUGO, INC.FACILITY NUMBER:
197610412
ADMINISTRATOR/
DIRECTOR:		NORAYR BADALYANFACILITY TYPE:
740
ADDRESS:3214 W. VERDUGO AVETELEPHONE:
(818) 433-7073
CITY:BURBANKSTATE: CAZIP CODE:
91505
CAPACITY: 6CENSUS: 4DATE:
09/27/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:35 AM
MET WITH:Ani KarapetyanTIME VISIT/
INSPECTION COMPLETED:
02:30 PM
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On 09/27/24, 9:35AM, Licensing Program Analyst (LPA) Raymond Comer arrived to conduct an unannounced annual visit of the Facility. LPA met with caregiver staff, who contacted Facility Administrator, Nvard Gevorkian, via cell phone. LPA spoke with the Administrator, and the reason for the visit was stated. At around 10:00AM, Administrator Designee, Ani Karapetyan, arrived at the facility to assist with LPA's inspection.

Facility is licensed as a single-story residence, fire clearance for six (6) non-ambulatory, and three (3) bedridden. Hospice Waiver Approved for two (2). Facility has four (4) private bedrooms, one (1) shared bedroom, and two (2) bathrooms.



At 10:15AM, LPA conducted a tour of the physical plant with the Administrator Designee and observed the following:

Physical plant was inspected for cleanliness and condition. Facility’s main door is the primary entry/exit access. Second exit point is located in rear area of facility, adjacent to bedroom#1.
Visitor Sign-in sheet, hand sanitizer, gloves and masks are available. Hand washing, coughing etiquette, and other signage are posted in the bathrooms, and throughout the facility. Room temperature is comfortable; wall thermostat displays a setting of 72.0°F. within the required range. Required postings are prominently displayed and observed to be current. Disaster drills were last conducted on June 2024.

Fire Detection system is present in the facility. Dual smoke/carbon monoxide detectors are located in bedrooms, and throughout the facility. Smoke and Carbon monoxide detectors were tested and function properly. LPA observed fire extinguisher hanging in the hallway, near the dining room. Purchase/Service Date: 09/27/2024.

[LIC 809-C] Continued

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Raymond Comer
LICENSING EVALUATOR SIGNATURE: DATE: 09/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/27/2024
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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: GRANT SERENITY OF VERDUGO, INC.
FACILITY NUMBER: 197610412
VISIT DATE: 09/27/2024
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Kitchen: At 11:00AM, LPA observed kitchen as clean, equipped with a functional stove, multiple appliances, with adequate supply of perishables and non-perishable food. Emergency food is stored and locked in laundry room area cabinet. Food is observed as properly labeled and stored. Kitchen cabinets store dishes, plastic, paper goods and utensils. Knives and sharps are stored and locked in kitchen drawer, and inaccessible to residents.

Medications were observed as stored in office room located between the living room and restroom. Medication area is locked and inaccessible to residents. Facility has fully stocked first aid kit and manual located and in the medication cabinet. Medications are listed on a centrally stored medication and destruction record log.


Laundry: LPA observed the laundry room located next to the kitchen. Laundry machines, soaps, and other cleaning agents are secured and inaccessible for residents. Linen storage observed to have adequate supply of linen and towels.

Garage: Garage is detached from the Facility. LPA observed garage as secured and inaccessible for residents. Garage is a equipped with multiple tier shelving units stocked with non-perishable food, can goods, dry cereals, snacks, emergency food, personal care items, incontinent supplies, paper towels, tissue, cleaning products, water, and PPE. Garage is equipped with a refrigerator storing, meats, vegetables, and fruit. Extra linen, towels, comforters PPE, and various other supplies.

Commons: LPA observed all common areas of the facility, including the resident dining area. LPA observed common areas to be clean, organized, properly furnished and in good condition. Furniture in common area was observed to be in good repair.

Bedrooms are observed as clean with sufficient lighting, properly furnished with bedding, linens, at least one chair, and night stand.

Bathrooms were observed to be clean and sanitary with necessary supplies and required safety fixtures (grab bars, anti-slip floor stripping). Hot water temperature measured at 108.5°F. Within the required range.

[LIC 809-C]-continued

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Raymond Comer
LICENSING EVALUATOR SIGNATURE:

DATE: 09/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2024
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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: GRANT SERENITY OF VERDUGO, INC.
FACILITY NUMBER: 197610412
VISIT DATE: 09/27/2024
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Outdoor (backyard) area observed to have a shaded patio, with table and sufficient seating for the residents. Outdoor furniture observed to be in good condition. All trash cans were observed to be covered. Outdoor area observed as clean and clear from obstruction. No bodies of water are located on the premises.

Resident records: All Resident's files were reviewed for current IPP and/or Needs and Services plans, physician report, and admission agreements. Resident records appeared to be complete and current.



Staff records: All Staff files were reviewed. Criminal record clearances were present and Staff are associated to this facility. Staff records appear to be complete and current.

There were no immediate health and safety hazards observed at the time of this inspection. Exit interview conducted and a copy of this report was provided.
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Raymond Comer
LICENSING EVALUATOR SIGNATURE:

DATE: 09/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2024
LIC809 (FAS) - (06/04)
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