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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610625
Report Date: 10/24/2024
Date Signed: 10/24/2024 12:54:49 PM

Document Has Been Signed on 10/24/2024 12:54 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:GUARDIAN ANGELS BOARD AND CAREFACILITY NUMBER:
197610625
ADMINISTRATOR/
DIRECTOR:		NSHANIAN, HERMINEFACILITY TYPE:
740
ADDRESS:11786 ENCINO AVETELEPHONE:
(818) 217-9444
CITY:GRANADA HILLSSTATE: CAZIP CODE:
91344
CAPACITY: 6CENSUS: 0DATE:
10/24/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:13 AM
MET WITH:Gor Khurshudyan, Silva SashikyanTIME VISIT/
INSPECTION COMPLETED:
01:00 PM
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Licensing Program Analyst (LPA) Michael Cava conducted a Pre-Licensing Inspection with the applicant representative and the administrator, Gor Khurshudyan and Silva Sashikyan. Their consultant, Lusina Tadevosyan, was also present. An Application to operate a Residential Care Facility for the Elderly (RCFE) was received by Community Care Licensing (CCL) on May 3, 2024. A fire clearance was approved on June 26, 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 a total of five (5) residents. The faciilty is a one story building. The smoke alarms and carbon monoxide detector are hard wired and inter-connected. The facility has a new fire extinguishers that was purchased on May 9, 2024. It is located in the kitchen.

A tour of the physical plant was initiated at approximately 10:30am 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 were adequate supplies of perishable and nonperishable food and dining ware to accommodate a maximum capacity of six (6). Knives will be kept in a locked drawer. Cleaning supplies will be kept in a locked cabinet beneath the sink. There is also an additional dining room table for staff.

BEDROOMS: There are four (4) bedrooms designated for client use. Bedroom #1 is private. Bedrooms #2, #3 and #4 are shared. Per STD 850, bedroom #2 only has a bedridden fire clearance. 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. All three bathrooms were observed to have the proper fixtures, grab bars, and non-skid mats. The hot water delivered in the bathrooms measured between 111 to 116 degrees.
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Michael Cava
LICENSING EVALUATOR SIGNATURE: DATE: 10/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/24/2024
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: GUARDIAN ANGELS BOARD AND CARE
FACILITY NUMBER: 197610625
VISIT DATE: 10/24/2024
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COMMON AREAS: These included the living room and dining room. The living room is equipped with three couches, two chairs, two tables, and a television. There is no fireplace. The dining room has a table large enough to seat between six (6) to eight (8) individuals. Dining room has an additional couch and coffee table. Bookshelf in the dining room carries some board games.

GARAGE/LAUNDRY ROOM: The laundry area is in the garage. The garage will also be utilized for storage, and will be kept locked and inaccessible to the residents.

OFFICE/STAFF WORKSTATION: Office is located across from the living room and dining room, where staff and resident records will be kept locked in a cabinet. 1st aid kit and manual also maintained in the staff office.

MEDICATIONS: Medications and medication records will be kept in another locked cabinet in the office.

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 floors and passageways were clean and in good repair. The backyard of the facility has a patio area and backyard furniture to accommodate the six (6) residents. The facility backyard also has sufficient yard space to hold outdoor activities. There is a swimming pool that is fenced all around with a gate that will be kept locked at all times. The fence surrounding the swimming pool is approximately 5 feet high all around its parameters.

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

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: 10/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2024
LIC809 (FAS) - (06/04)
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