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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610612
Report Date: 09/27/2024
Date Signed: 09/27/2024 01:34:34 PM

Document Has Been Signed on 09/27/2024 01:34 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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:CONCORDIA BOARD & CAREFACILITY NUMBER:
197610612
ADMINISTRATOR/
DIRECTOR:		ARUTIUNIAN, EMMAFACILITY TYPE:
740
ADDRESS:16710 BLACKHAWK STREETTELEPHONE:
(818) 403-1803
CITY:GRANADA HILLSSTATE: CAZIP CODE:
91344
CAPACITY: 6CENSUS: 0DATE:
09/27/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:20 AM
MET WITH:Emma Arutiunian, Nazar "Nick" YegeyanTIME VISIT/
INSPECTION COMPLETED:
01:30 PM
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Licensing Program Analyst (LPA) Michael Cava conducted a Pre-Licensing Inspection with the applicant representatives and administrators, Emma Arutiunian and Nazar "Nick" Yegeyan. An Application to operate a Residential Care Facility for the Elderly (RCFE) was received by Community Care Licensing (CCL) on April 10, 2024. The facility is a one story building. A fire clearance was approved on August 7, 2024 for five (5) non-ambulatory residents and one (1) bedridden resident, for a total capacity of six. The bedridden fire clearance is assigned to room #2. The applicant is also requesting a hospice waiver to retain four (4) residents. The smoke alarms and carbon monoxide detector are dual and and inter-connected. There is a new fire extinguisher that was purchased on September 6, 2024, located in dining room/kitchen area.

A tour of the physical plant was initiated at approximately 11am and the following was observed:

KITCHEN: The kitchen is equipped with a refrigerator, microwave oven, stove/oven and sink. There were adequate supplies of dining ware to accommodate a maximum capacity of six (6). Knives will be locked in a kitchen drawer. Currently no residents residing in the home, therefore, no perishable food required at this time. Applicant is aware that they will need to supply perishable food once license is approved. Facility does have an adequate supply of emergency/non-perishable food items.

BEDROOMS: There are six (6) bedrooms designated for client use. Per STD 850, Bedroom #2 has a bedridden fire clearance. All six bedrooms are private. The applicant furnished each bedroom with a bed, night stand, chair, dresser, bedding and linen. The bedrooms have sufficient lighting and closet space.

BATHROOMS: The facility has four (4) full bathrooms and two (2) half. Bedrooms #3 and #4 has it's own bathroom. The other two full bathrooms are in the hallway. The two half bathrooms are designated for staff and visitors only. The bathrooms designated for the residents use were observed to have the proper fixtures, grab bars, and non-skid mats. Hot water delivered in the bathrooms measured between 105-106 degrees.

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Michael Cava
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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: CONCORDIA BOARD & CARE
FACILITY NUMBER: 197610612
VISIT DATE: 09/27/2024
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COMMON AREAS: These included the living room and dining room. The dining room has a large dining room table capable to seat up to eight persons. Applicant has placed an order for a couch and coffee table for the living room. Order was placed on August 25, 2024. Currently awaiting the order, but should be delivered within a week. Telephone/internet service will be installed by Tuesday, October 1, 2024. Facility has no fireplace. Cleaning supplies will be kept in a locked hallway closet. There were no visible immediate hazards.

LAUNDRY ROOM: The laundry room is located in between rooms #4 & #5. Room will be kept locked at all times. Detergents and cleaning supplies will also be maintained locked in the laundry room.

MEDICATIONS: Medications and medication records will be kept in a locked cabinet in the living room.

STAFF/RESIDENT RECORDS: Staff and resident records will be maintained in the same cabinet as medications, that is locked in the living room.

SURROUNDING GROUNDS: Passageways, entrance/exits to the home was clear of obstruction. All entry and exit doors have a functional auditory alert when the doors open. There is furniture appropriate for outdoor use. There is no swimming pool, or any bodies of water. There is sufficient yard space to hold some outside activities. The backyard of the facility has a patio and backyard furniture to accommodate the six (6) residents.

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

Prior to licensure, the applicant will need to submit photos the couch and coffee table in place at the living room area. Applicant will also need to submit invoice/receipt of when the telephone and internet line is connected. Otherwise, pursuant to Title 22, Division 6 of the CA Code of Regulations, the rest of the facility's physical environment appears to be compliant. CAB will be advised and a copy of this report provided.

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Michael Cava
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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