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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603601
Report Date: 10/24/2022
Date Signed: 10/24/2022 01:17:40 PM

Document Has Been Signed on 10/24/2022 01:17 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:GRANT SERENITY OF DEL MAR INC.FACILITY NUMBER:
198603601
ADMINISTRATOR:GEVORKIAN, NVARDFACILITY TYPE:
740
ADDRESS:3049 E. DEL MAR BLVDTELEPHONE:
(818) 425-6797
CITY:PASADENASTATE: CAZIP CODE:
91107
CAPACITY: 6CENSUS: 3DATE:
10/24/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
08:42 AM
MET WITH:Nvard Gevorkian - Applicant TIME COMPLETED:
12:00 PM
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Licensing Program Analyst(s)(LPA) Mary Flores conducted an announced pre-licensing visit at the facility. LPA Flores met with Nvard Gevorkian - applicant. Facility was approved by the Fire Department on 8/11/22 for 6 residents 60 years and over of which 5 may be non-ambulatory and 1 bedridden.

Facility consist of a living room, a dining room, a kitchen, 4 resident bedrooms, 2 bathrooms, a laundry area, a backyard, and a garage.
LPA Flores conducted a tour of the facility with Nvard Gevorkian applicant and observed the following:
Living room has an electrical fire place that is covered. Dining room has sufficient sitting area. Laundry area is locked and laundry supplies are maintained. Kitchen area is clean, sharps are locked in cabinet by refrigerator, medication cabinet and medication refrigerator are locked. Cleaning supplies are locked under the sink. Food supplies were observed sufficient for 2 days of perishables and 7 days of non-perishables.
Residents' bedrooms (4) were observed with all required furniture, bedding, and sufficient lighting.Oxygen signs are posted in the bedrooms using oxygen. Bathrooms #1(B1) and #2(B2) were observed to have the required grab bars and skid mats. Water temperature was tested as follow B1 tested at 115.7 degrees F., and B2 tested at 114.2 degrees F., which is within the required 105-120 degrees F. Interlace smoke detectors and carbon monoxide detector were tested and in working condition. Exit doors have a sound device and they are in working condition. No large bodies of water were observed. Backyard patio has shaded sitting area. Garage is not accessible to residents and is used to store facility's supplies. Resident #2(R2) and #3(R3) are noted as bedridden facility was approved for 1 bedridden resident. Medication was reviewed for 3 residents. R3 has PRN supplement medications without labels. Files were reviewed for 3 residents R2 last physician report was on 3/29/21 notes resident as bedridden, no TB test clearance on record for R2, and R3's last physician report was on 9/14/21 and notes R3 as non-ambulatory and bedridden. LPA reviewed files for 3 staff.

LPA Flores conducted Component III with Nvard Gevorkian applicant.
SUPERVISORS NAME: Stefanie Coronel
LICENSING EVALUATOR NAME: Mary G Flores
LICENSING EVALUATOR SIGNATURE: DATE: 10/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/24/2022
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, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: GRANT SERENITY OF DEL MAR INC.
FACILITY NUMBER: 198603601
VISIT DATE: 10/24/2022
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The following items must be corrected and proof of correction must be submitted within 7 days:
  • Applicant will obtain fire clearance for 2 bedridden residents or obtain physician's report for R3 with current assessment for ambulatory status.
  • Applicant must ensure R3's PRN (supplements) are label.
  • Applicant will obtain current Physician's report for R2 and R3.


Facility does not meet Title 22 regulations at the time of the visit.

Exit interview was conducted and a copy of this report was provided.
SUPERVISORS NAME: Stefanie Coronel
LICENSING EVALUATOR NAME: Mary G Flores
LICENSING EVALUATOR SIGNATURE:

DATE: 10/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2022
LIC809 (FAS) - (06/04)
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