<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603601
Report Date: 11/18/2022
Date Signed: 11/18/2022 12:17:12 PM

Document Has Been Signed on 11/18/2022 12:17 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: 2DATE:
11/18/2022
TYPE OF VISIT:Case Management - OtherANNOUNCEDTIME BEGAN:
11:57 AM
MET WITH:Nvard Gevorkian - Applicant TIME COMPLETED:
12:30 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst(s) (LPA) Mary Flores conducted a case management visit to follow up on pre-licensing visit conducted on 10/24/22. LPA Flores met with Nvard Gevorkian applicant.

On 10/24/22 LPA Flores conducted a pre-licensing visit and the following corrections were observed:
  • 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.


On 11/18/22 LPA Flores observed the following:
  • Applicant conducted a physician assessment dated 10/24/22 which notes R3 status is non-ambulatory. Facility currently has 1 bedridden resident (R2) and is currently operating within the license requirements.
  • R3's PRN and supplements are label.
  • Annual medical assessments were conducted for R2 and R3 and dated 10/24/22.


Facility's physical plant is cleared and facility is meeting Title 22 Regulations.

Exit interview was conducted with Nvard Gevorkian applicant and a copy of this report was provided.
SUPERVISORS NAME: Stefanie Coronel
LICENSING EVALUATOR NAME: Mary G Flores
LICENSING EVALUATOR SIGNATURE: DATE: 11/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/18/2022
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 1