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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610553
Report Date: 05/10/2024
Date Signed: 05/10/2024 01:07:07 PM

Document Has Been Signed on 05/10/2024 01:07 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 GRANADA HILLS INCFACILITY NUMBER:
197610553
ADMINISTRATOR/
DIRECTOR:		GEVORKIAN, NVARDFACILITY TYPE:
740
ADDRESS:10879 LOUISE AVETELEPHONE:
(818) 425-6797
CITY:GRANADA HILLSSTATE: CAZIP CODE:
91344
CAPACITY: 6CENSUS: 0DATE:
05/10/2024
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:NVARD GEVORKIAN-ADMINISTRATORTIME VISIT/
INSPECTION COMPLETED:
02:15 PM
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At 10:00am Licensing Program Analyst (LPA) Perchui Milena Khurshudyan conducted an announced Pre-Licensing Inspection and met with the facility administrator Nvard Gevorkian.

An application was submitted to Community Care Licensing Division-CCLD on 01/02/2024, Initial license for a Residential Care Facility for the Elderly, 60 years and older. A fire clearance was approved on April 24, 2024 for five (5) non-ambulatory residents and one (1) bedridden resident, for a total capacity of six (6). The bedridden fire clearance is for bedrooms #1, #2, and #3. Bedrooms #4, #5, #6 cleared for non-ambulatory residents. The applicant also requested a hospice waiver and granted for two (2) residents. The facility is a single-story home.
A tour of the physical plant was initiated at approximately 10:15am and the following was observed:

KITCHEN: The facility has a kitchen area that is equipped with a refrigerator, microwave oven and sink. There were adequate supplies of perishable and nonperishable food and dining ware to accommodate a maximum capacity of six (6). Knives and sharps were observed to be locked in a kitchen drawer and inaccessible.

BEDROOMS: There are six (6) bedrooms designated for residents’ private use. All bedrooms are furnished and well equipped with bed, nightstand, chair, dresser, bedding, and extra linen. Rooms were observed to have sufficient lighting and closet space. Auditory alarms were tested and observed to be operational at 10:35am. Facility will have awake staff.

BATHROOMS: The facility has two (2) bathrooms, bathroom #1 designated for the residents’ use, bathroom #2 is designated for staff. Both bathrooms were observed to have the proper fixtures, grab bars, and non-skid mats. The hot water delivered in the bathrooms measured at 10:45am to be at 117°F degrees.

Continue on LIC809-C

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Perchui Khurshudyan
LICENSING EVALUATOR SIGNATURE: DATE: 05/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/10/2024
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.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: GRANT SERENITY OF GRANADA HILLS INC
FACILITY NUMBER: 197610553
VISIT DATE: 05/10/2024
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MEDICATION: LPA observed medication and facility staff/resident files will be kept locked in the separate storage room inside the locked cabinet and inaccessible to residents in care. Emergency call buttons will be provided to residents. Facility has Dementia Care Program.

SMOKE DETECTORS/CARBON MONOXIDE. The smoke detectors and carbon monoxide are inter-connected and were located throughout the facility. At 11:00am they were tested and observed to be operational. The facility has two (2) new fire extinguishers that were purchased on March 6, 2024. One fire extinguisher is located in the dining/living room area, and the second one is in the kitchen.

COMMON AREAS: The facility maintains a comfortable temperature at 69°F. The living room and dining appeared clean and were properly furnished. No obstructions and or tripping hazards throughout the facility. LPA observed puzzles, books, balls, and board games to provide activities to residents in care.

SURROUNDING GROUNDS: In the back of the facility has sufficient yard space. LPA observed appropriate outdoor furniture, with covered shaded area for residents. The backyard is fenced. LPA discussed the importance of maintaining the care and supervision to meet the needs of clients. There are no bodies of water.

GARAGE: The garage is currently being used for storage. The LPA observed the garage locked and inaccessible to residents in care. LPA observed laundry room is located in the separate locked area between kitchen and living room. The washer/dryer appear to be new and in good condition. Laundry supplies are kept locked inaccessible when not in use with supervision.

Component III was conducted with the Administrator.

Facility is in compliance with Title 22 Regulations at this time. This report will be forwarded to the Centralized Application Bureau (CAB) and will be notified by the CAB Analyst when the license has been approved.

Exit interview was conducted and a copy of this report was provided to the Applicant/Administrator.

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Perchui Khurshudyan
LICENSING EVALUATOR SIGNATURE:

DATE: 05/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2024
LIC809 (FAS) - (06/04)
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