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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610490
Report Date: 11/03/2023
Date Signed: 11/03/2023 10:41:26 AM

Document Has Been Signed on 11/03/2023 10:41 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
CENTRALIZED APP UNIT, 744 P STREET, MS 9-14-8201
SACRAMENTO, CA 95814
FACILITY NAME:ARCHWOOD ASSISTED LIVINGFACILITY NUMBER:
197610490
ADMINISTRATOR:DISHOYAN, ARMINEFACILITY TYPE:
740
ADDRESS:17981 ARCHWOOD STREETTELEPHONE:
(747) 788-0208
CITY:RESEDASTATE: CAZIP CODE:
91335
CAPACITY: 6CENSUS: DATE:
11/03/2023
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Armine Dishoyan Administrator, Alina Solloway, Licensee; Tammy Edwards, analyst.TIME COMPLETED:
10:30 AM
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COMP II by CAB successfully completed

Facility Type: RCFE
Application Type: INITIAL
Capacity: 6
Census (if any clients in care): 0
Method: Telephone call with CAB
COMP II Participants: Armine Dishoyan Administrator, Alina Solloway, Licensee; Tammy Edwards, analyst.

Applicant/administrator participated in COMP II at CAB via telephone call with analyst at CAB. Identification of the applicant and administrator was verified by confirming driver’s license number. During COMP II, applicant and administrator confirmed the understanding of Title 22. Component II was successfully completed. Applicant and administrator were advised to email/fax signed LIC 809 with copy of photo ID to CAB.

During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas:
1. Facility operation: License type, client/resident populations, and program
2. Admission Policies
3. Staffing requirements & Training
4. Restrictive/Prohibited Health Conditions
5. General provisions
6. Emergency Preparedness
7. Complaints & Reporting
8. Pre-licensing readiness
SUPERVISORS NAME: Darla Neeley
LICENSING EVALUATOR NAME: Tammy Edwards
LICENSING EVALUATOR SIGNATURE: DATE: 11/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/03/2023
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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