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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610619
Report Date: 01/14/2025
Date Signed: 01/14/2025 03:13:49 PM

Document Has Been Signed on 01/14/2025 03:13 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:OLIVE BRANCH ESTATE INC.FACILITY NUMBER:
197610619
ADMINISTRATOR/
DIRECTOR:		BOYADZHYAN, ARMENFACILITY TYPE:
740
ADDRESS:17107 MANDARIN COURTTELEPHONE:
(818) 568-6443
CITY:GRANADA HILLSSTATE: CAZIP CODE:
91344
CAPACITY: 6CENSUS: 0DATE:
01/14/2025
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:37 PM
MET WITH:Armen Boyadzhyan, Marine GazdzhyanTIME VISIT/
INSPECTION COMPLETED:
03:15 PM
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Licensing Program Analysts (LPAa) Nadia Shahbazian and Michael Cava conducted a Pre-Licensing Inspection with the applicant representative and administrators Armen Boyadzhyan and Marine Gazdzhyan. An Application to operate a Residential Care Facility for the Elderly (RCFE) was received by Community Care Licensing (CCL) on April 16, 2024. A fire clearance was approved on December 13, 2024 for five (5) non-ambulatory residents and one (1) bedridden resident, for a total capacity of six. The applicant is also requesting a hospice waiver to retain six (6) residents. The smoke alarms and carbon monoxide detector are dual and interconnected. The facility has one new fire extinguishers that was purchased on December 12, 2024. Fire extinguisher is located in the kitchen.

A tour of the physical plant was initiated at approximately 2:00pm and the following was observed:

KITCHEN: The facility has a Kitchen area that is equipped with a refrigerator and microwave oven. There was an adequate supply of perishable and nonperishable food and dining ware to accommodate a maximum capacity of six (6). Knives were observed locked in a kitchen drawer.

BEDROOMS: There are five (5) bedrooms designated for client use. Bedrooms #1, #2, #3, and #5 are private. Bedroom #4 is shared. The applicant furnished the resident bedrooms with beds, night stand, chairs, dresser, bedding and linen. The bedrooms have sufficient lighting and closet space. Per STD 850, Bedroom #1 is cleared for fire-clearance.

BATHROOMS: The facility has two (2) bathrooms. The bathrooms were observed to have the proper fixtures, grab bars, and non-skid mats. The hot water delivered in the bathrooms measured at 108 degrees.
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Michael Cava
LICENSING EVALUATOR SIGNATURE: DATE: 01/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/14/2025
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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: OLIVE BRANCH ESTATE INC.
FACILITY NUMBER: 197610619
VISIT DATE: 01/14/2025
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COMMON AREAS: These included the living room and dining room area. The living room has a couch, two chairs, table and television. The dining room table is large enough to seat up to six (6) residents. There is no fireplace. There were no visible immediate hazards.

LAUNDRY ROOM: The laundry room is located in between rooms #1 and #2. Detergents and cleaning supplies are kept inside. The laundry room is locked, and requires combination code to access.

MEDICATIONS: The medication closet is located in the hallway by room #3. Medication closet will be kept locked and requires a combination code to access.

Resident/Staff Records: Resident and staff records will be kept locked in the same closet as medications.

SURROUNDING GROUNDS: The driveway, passageways and entrance to the home was clear of obstruction. All entry and exit doors have a functional auditory alert when the doors open. The backyard of the facility has a patio and backyard furniture to accommodate the six (6) residents. The facility backyard has sufficient yard space. There is no swimming pool or any other bodies of water.

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

Pursuant to Title 22, Division 6 of the CA Code of Regulations, the facility's physical environment appears to be compliant and 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: 01/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/14/2025
LIC809 (FAS) - (06/04)
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