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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610571
Report Date: 07/02/2024
Date Signed: 07/03/2024 09:41:56 AM

Document Has Been Signed on 07/03/2024 09:41 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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:KLN BOARDING CAREFACILITY NUMBER:
197610571
ADMINISTRATOR/
DIRECTOR:		GEVORGYAN, ERNAFACILITY TYPE:
740
ADDRESS:8706 HERRICK AVENUETELEPHONE:
(818) 406-3301
CITY:SUN VALLEYSTATE: CAZIP CODE:
91352
CAPACITY: 6CENSUS: 0DATE:
07/02/2024
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Kathrine Nagapetyan, LicenseeTIME VISIT/
INSPECTION COMPLETED:
12:00 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
At 9:30am Licensing Program Analysts (LPA) Leizl de la Cerra conducted an announced Pre-Licensing Inspection to the above facility and met with Licensee Kathrine Nagapetyan. The LPA will inspect the facility to ensure that the facility is in compliance with the rules and regulations under California Code of Regulations, Title 22, Division 6.

Fire Clearance was approved on 02/29/2024 for a maximum capacity of six (6) residents, of which five (5) are for non-ambulatory and one (1) for a bedridden resident in room #1. Facility was also approved for a Hospice waiver for six (6) residents on February 01, 2024. The facility is a single-story building. At 9:45am, with the assistance of the Licensee, LPA conducted a facility tour of both the inside and outside premises and observed the following:

KITCHEN: The kitchen is equipped with a refrigerator, microwave oven and sink. At 9:50am, the team observed adequate supplies of perishable and nonperishable food and dining ware to accommodate a maximum capacity of six (6). All knives and sharps are observed to be locked in a kitchen drawer and inaccessible to residents. The medications will be kept in the kitchen cabinet and LPA observed the cabinet is locked and inaccessible to residents in care. The first-aid kit is complete. There is a three drawer locked cabinet and will contain resident and staff records.
The facility smoke alarm system is hard wired and interconnected. The fire extinguisher is located near the dining area and was observed to be fully charged and was last purchased on 02/27/24. The facility uses a dual Carbon Monoxide/Smoke alarm detectors all over the common areas of the facility. Alarms were tested and observed to be operational.
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Leizl De La Cerra
LICENSING EVALUATOR SIGNATURE: DATE: 07/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/02/2024
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: KLN BOARDING CARE
FACILITY NUMBER: 197610571
VISIT DATE: 07/02/2024
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
26
27
28
29
30
31
32
BEDROOMS: There are four (4) bedrooms designated for client use. Bedrooms #2 #3 and #4 are cleared for five (5) non-ambulatory residents and bedroom #1 is cleared for one (1) bedridden. . All bedrooms are furnished with beds, night stands, chair, flashlights, caregiver pager/call button and required bedding and linen. The bedrooms have sufficient closet space and have sufficient lighting.
BATHROOMS: At 10:25am LPA observed two (2) bathrooms that are clean and in good repair. Properly supplied with toilet papers, soap and paper towels. The hot water temperature measured between 112°- 115°F. observed the appropriate grab bars and have non-skid mats.
COMMON AREAS: The facility maintains a comfortable temperature at 73°F. The living room and dining appeared clean and were properly furnished. No obstructions and or tripping hazards throughout the facility. The fireplace located in the living room is adequately closed and inaccessible.

SURROUNDING GROUNDS: At 10:35 LPA observed the back of the facility. There is sufficient yard space. LPA observed appropriate outdoor furniture, with a covered shaded area for clients. There is a pool in the backyard which is fenced and locked, inaccessible to the residents. The fence surrounding the swimming pool is approximately 5 feet high all around. A key is needed to gain entry to the swimming pool as it is kept locked at all times.


GARAGE: LPA observe the garage is separate from the house. The garage is locked and inaccessible to residents in care.
LAUNDRY ROOM: LPA observed laundry room which has a lock and is located by the kitchen area. The washer/dryer appear to be in good condition. Laundry supplies are kept inaccessible when not in use. Cleaning supplies were also kept in the laundry room which is inaccessible to clients.

Component III Orientation was conducted with the administrator/applicant during the visit.
LPA de la Cerra will notify the Centralized Applications Bureau (CAB) Analyst of the completed Pre-Licensing inspection. The CAB Analyst will notify applicant when license is approved.
Exit interview was conducted and a copy of the signed report has been emailed to the applicant.
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Leizl De La Cerra
LICENSING EVALUATOR SIGNATURE:

DATE: 07/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2