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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610573
Report Date: 10/02/2024
Date Signed: 10/02/2024 11:35:50 AM

Document Has Been Signed on 10/02/2024 11:35 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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:HASKELL HOUSEFACILITY NUMBER:
197610573
ADMINISTRATOR/
DIRECTOR:		VANOYAN, ERNAFACILITY TYPE:
740
ADDRESS:11422 HASKELL AVE.TELEPHONE:
(640) 900-0099
CITY:GRANADA HILLSSTATE: CAZIP CODE:
91344
CAPACITY: 6CENSUS: 0DATE:
10/02/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:02 AM
MET WITH:Marine Navruzyan, Erna VanoyanTIME VISIT/
INSPECTION COMPLETED:
11:45 AM
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Licensing Program Analyst (LPA) Michael Cava conducted a Pre-Licensing Inspection with the applicant/licensee Marine Navruzyan, and administrators, Erna Vanoyan and Ani Navruzyan. An Application to operate a Residential Care Facility for the Elderly (RCFE) was received by Community Care Licensing (CCL) on February 12, 2024. A fire clearance was approved on September 9, 2024 for five (5) non-ambulatory residents and one (1) bedridden resident, for a total capacity of six. The facility is a one story building. The smoke alarms and carbon monoxide detector are dual and interconnected. The facility has one fire extinguishers that was purchased on July 13, 2024. It is located in the kitchen.

A tour of the physical plant was initiated at approximately 10:00am and the following was observed:

KITCHEN: The facility has a Kitchen area that is equipped with a refrigerator, stove/oven, microwave oven and sink. There is an adequate supply of nonperishable food and dining ware to accommodate a maximum capacity of six (6). In addition to the nonperishable food items, the applicant keeps an emergency food supply in the pantry. No perishable food at this time, as there are no residents. Licensee was advised to keep a supply perishable food items when their license is obtained. Knives were observed locked in a kitchen drawer.

BEDROOMS: There are six (6) bedrooms. Five (5) are designated for client use. One bedroom is reserved for staff. Per STD 850, Bedroom #1 has a bedridden fire clearance. Bedroom #1 is also a shared room. Bedrooms #2, #3, #4 and #5 are private rooms. The applicant furnished the resident bedrooms with beds, night stand, chairs, dresser, bedding and linen. The bedrooms have sufficient lighting and closet space.

BATHROOMS: The facility has three (3) bathrooms. Bedrooms #1 and #4 has it's own bathroom with shower. The third bathroom is located in the hallway. All three bathrooms were observed to have the proper
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Michael Cava
LICENSING EVALUATOR SIGNATURE: DATE: 10/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/02/2024
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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: HASKELL HOUSE
FACILITY NUMBER: 197610573
VISIT DATE: 10/02/2024
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fixtures, grab bars, and non-skid mats. The hot water delivered in the bathrooms measured between 108 and 110 degrees.

COMMON AREAS: These included the living room and dining room. The living room is furnished with a couch, coffee table and television. There is a fireplace that is screened, but non-operational. No fireplace tools present. The dining room table is large enough to seat up to six (6) residents. There is an additional couch located by the dining room. There were no visible immediate hazards inside of the facility.



LAUNDRY ROOM: The laundry room is located next to the kitchen. The washer and dryer are brand new. Detergents and cleaning supplies will be kept separately in a locked closet.

MEDICATIONS: The medications and medication records will be kept in a locked cabinet in the kitchen.

OFFICE, STAFF BEDROOM & BREAKROOM: Staff office is located by the front entrance. Resident and personnel files will be maintained in a locked filing cabinet there. The staff bedroom is located by the dining room. Room was furnished with a bed and closet space. The kitchen had an additional table to seat up to four staff for their break.

SURROUNDING GROUNDS: Passageways and entrance to the home was clear of obstruction. All entry and exit doors have a functional auditory alert when the doors open. There is a swimming pool in the backyard surrounded by a six foot fence all around and a locked gate to deny resident access. The front yard has patio furniture appropriate for outdoor use and to accommodate the six residents.

GARAGE: The garage is not attached to the home. It is located at the backyard. The garage will be used for extra storage. It will be kept locked and inaccessible to residents at all times.

In addition to the Pre-Licensing inspection, a Component III power point presentation was held prior to the physical plant inspection. .

Pursuant to Title 22, Division 6 of the CA Code of Regulations, the physical plant is compliant and the facility is ready for licensure. CAB will be advised and a copy of this report provided.

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Michael Cava
LICENSING EVALUATOR SIGNATURE:

DATE: 10/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/02/2024
LIC809 (FAS) - (06/04)
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