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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610657
Report Date: 10/24/2024
Date Signed: 10/24/2024 11:53:44 AM

Document Has Been Signed on 10/24/2024 11:53 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:G & A BOARDING CAREFACILITY NUMBER:
197610657
ADMINISTRATOR/
DIRECTOR:		SHAMAMYAN, GRIGORFACILITY TYPE:
740
ADDRESS:7001 GARDEN GROVE AVENUETELEPHONE:
(818) 359-7379
CITY:RESEDASTATE: CAZIP CODE:
91335
CAPACITY: 6CENSUS: 0DATE:
10/24/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Gregor Greg Shamamyan, AdministratorTIME VISIT/
INSPECTION COMPLETED:
12:30 PM
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At 09:30 AM, Licensing Program Analyst (LPA), Huma Rahimi conducted an announced Pre-Licensing visit to the above facility and met with Gregor Greg Shamamyan, Licensee/Administrator, and explained the reason for the visit. At the time of this visit LPA did not observe any residents present in the facility. Fire Clearance dated 08/15/2024 and received for five (5) Non-ambulatory, and one (1) Bedridden (room #4) residents. The purpose of today’s visit is to inspect the facility to ensure that the facility is in compliance with rules and regulations under California Code of Regulations, Title 22, Division 6. The facility is a single-story building. Today's site visit consisted of LPA touring the physical plant inside and outside and observed the following:

KITCHEN: The facility has a Kitchen area that is equipped with a refrigerator, microwave oven, and a sink. Stove was observed in a good working condition. At 09:25am, LPA 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 cabinet and inaccessible to residents. LPA observed two Fire Extinguishers and were last purchased on 06/08/2024. They were observed hanging on the wall in the kitchen.

MEDICATION ROOM: The centrally stored medication will be kept in the in the locked kitchen cabinet. Residents and staff files will be kept locked in the living room inaccessible to residents.



BEDROOMS: There are four (4) bedrooms designated for resident’s use. Bedrooms number one (1) and three (3) are shared. Bedroom (4) is used for a bedridden resident and bedroom (2) is private. All bedrooms are furnished with beds, dressers and required bedding and linen. The bedrooms have sufficient closet space and have sufficient lighting. Auditory alarms were tested and observed to be operational.
Continue on LIC 809C
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Huma Rahimi
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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: G & A BOARDING CARE
FACILITY NUMBER: 197610657
VISIT DATE: 10/24/2024
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BATHROOMS: There are two (2) bathrooms at the facility. Bathroom # (1) is in the living room and bathroom # (2) is by the bedroom # (4). LPA observed all bathrooms are clean and in good repair. Properly supplied with toilet papers, soap and paper towels. LPA observed appropriate grab bar and had non-skid mat The water temperature was noted at 110.3°.

LAUNDRY ROOM: The laundry room is located by the kitchen in a locked closet where all cleaning supplies and laundry detergents will be kept. All cleaning supplies and laundry detergents are kept inaccessible to residents in care. The washer/dryer appear to be in good working condition.

COMMON AREAS: The facility maintains a comfortable temperature at 73°F. The living room and dining area
appeared clean and were properly furnished and has a television. No obstructions and or tripping hazards throughout the facility. LPA observed a working telephone for the facility.

SURROUNDING GROUNDS: The facility has sufficient front yard space. LPA did observe appropriate outdoor furniture in the backyard of the facility that can accommodate six (6) residents, LPA observe a covered shaded area for residents with some games for outdoor activities. There is no swimming pool or any bodies of water at the facility. The exit was free of any obstruction or hazard.

Garage/Storage: The facility does not have any extra garage/storage space.

SMOKE DETECTORS/CARBON MONOXIDE. Smoke detectors and carbon monoxide were located throughout the facility. At 9:55 AM, they were tested and observed to be operational.

Component III was conducted with the Licensee/Administrator.



Facility is in compliance with Title 22 Regulations at this time. This report will be forwarded to the Centralized Application Bureau (CAB) and be notified by the CAB Analyst when your license has been approved.

Exit interview was conducted and with a copy of this report was provided to the Applicant/Administrator.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Huma Rahimi
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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