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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603555
Report Date: 05/19/2022
Date Signed: 05/19/2022 12:05:41 PM

Document Has Been Signed on 05/19/2022 12:05 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, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:CIRCLE OF GRACE, INC.FACILITY NUMBER:
198603555
ADMINISTRATOR:KHACHATRYAN, ANNAFACILITY TYPE:
740
ADDRESS:7157 HIDDEN PINE DRTELEPHONE:
(818) 425-6797
CITY:SAN GABRIELSTATE: CAZIP CODE:
91775
CAPACITY: 6CENSUS: 0DATE:
05/19/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:25 AM
MET WITH:Nvard Gevorkian, LicenseeTIME COMPLETED:
12:10 PM
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Licensing Program Analysts (LPAs) Galarza and Valeria Maldonado made an Announced visit and met with Licensee Nvard Gevorkian and Administrator Anna Khachatryan to conduct a Pre-Licensing evaluation.

An application was submitted to Community Care Licensing Department (CCLD) on for an initial application of a Residential Care Facilities for the Elderly (RCFE) to serve adults ages 60 and over. A hospice waiver for two (2) is in place. Dementia Plan is in place. The requested capacity is for six (6) [5 non-ambulatory & 1 bedridden in room #4]. Structure: Facility is a single-story home located in a residential area consisting of six (6) bedrooms, two (2) full bathrooms, kitchen, dining room, living room, laundry room, and attached garage.. Front yard is landscaped with grass. Bedroom Clients: Each bedroom is designated as a private bedroom. Bedrooms are equipped with one bed, night-stand, chair, lamp, and overhead lightning.Bathrooms: Have a working toilet, wash basin, and shower. One (1) bathroom has a walk-in shower. Linens & Hygiene Supplies: All beds had the required linen/supplies which include, pillowcase, mattress pads, fitted sheet, blanket and bedspreads. Adequate supply of linens is stored in bedroom closets. Emergency Phone Numbers, Exit Plan: Emergency numbers are posted and readily available for review. Two (2) fully charged fire extinguishers were observed. Facility has a land line telephone. Food Service: Dishes, cups, and flatware are stored in the kitchen cupboards, inspected and in good repair. Knives, cutlery, and other sharp kitchen utensils were observed locked and inaccessible. Adequate food supply is stored in the kitchen and consists of the following: 2-day perishables, and 7-day non-perishables. Smoke Detectors: There are electrical & inter-connected smoke detectors located in all bedrooms, common areas, and hallways. Appliances: Refrigerator, oven, microwave, dishwasher and washer/dryer are in working condition. The residence is equipped with central forced heating. Toxins: Cleaning supplies, and toxins are locked only accessible to staff.

See LIC 809C for report continuation.

SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Noemi Galarza
LICENSING EVALUATOR SIGNATURE: DATE: 05/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/19/2022
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, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: CIRCLE OF GRACE, INC.
FACILITY NUMBER: 198603555
VISIT DATE: 05/19/2022
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Water Temperature: Hot water was tested in all bathrooms, and kitchen sink. Water temperature was not within normal limits 105 degrees Fahrenheit (40.5 degrees C) and not more than 120 degrees Fahrenheit (48.8 degrees C). Medication, First-Aid Kit & Book: Designated centrally stored medications cabinet, and the first-aid kit has been inspected which has at least the following: tweezers, scissors, antiseptic, bandages, gauze, thermometer; including a current First Aid manual. Clients & Staff Files: Designated area for files will be in the garage. Pools/Jacuzzi/Body of Water & Pets: The backyard has two (2) water fountains. Fire Clearance: Fire clearance is approved on 5/4/2022 for five (5) non-ambulatory residents and one (1) bedridden resident. Per Fire Marshall the facility was required to install fire doors; which were tested and observed operational. Component III: Component III was waived.

No items of correction were identified.

An exit interview was conducted, and a copy of this report has been furnished to Licensee. Accordingly, LPA will submit a copy of this facility evaluation report to the Central Applications Bureau (CAB) for review. If the applicant has questions regarding the status of the application, they have been instructed to communicate with the CAB Analyst assigned to their application.


SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Noemi Galarza
LICENSING EVALUATOR SIGNATURE:

DATE: 05/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2022
LIC809 (FAS) - (06/04)
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