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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603695
Report Date: 01/11/2024
Date Signed: 01/11/2024 11:54:23 AM

Document Has Been Signed on 01/11/2024 11:54 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:GRANT SERENITY ON CHARLOTTE, INC.FACILITY NUMBER:
198603695
ADMINISTRATOR:KARAPETYAN, ANIFACILITY TYPE:
740
ADDRESS:5588 N.CHARLOTTE AVENUETELEPHONE:
(747) 474-1523
CITY:SAN GABRIELSTATE: CAZIP CODE:
91776
CAPACITY: 6CENSUS: 0DATE:
01/11/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Nvard Gevorkian, LicenseeTIME COMPLETED:
11:55 PM
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Licensing Program Analysts (LPAs) Galarza and Sanjay Vaid made an announced visit and met with Licensee Nvard Gevorkian 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 Dementia waiver and a hospice waiver for three (3) is in place. The requested capacity is for six (6) non-ambulatory, of which one may be bedridden in rooms #5 or #6. Structure: Facility is a single-story home located in a residential area consisting of six (6) private bedrooms, two (2) bathrooms, kitchen, dining room, living room, laundry area in attached garage with 2 parking spaces, backyard outdoor covered patio, storage shed in the rear of the backyard. Front yard is landscaped with grass and back yard is landscaped with gravel. Bedroom Clients: Each bedroom is designated as a private bedroom. Bedrooms are equipped with one bed, night-stand, chair, lamp, and overhead lighting. Bathrooms: Two (2) full bathrooms equipped with working toilets, wash basins, bathtub/ 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. Emergency water supply was observed. 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 new condition. The residence is equipped with central heating and air conditioning. Toxins: Cleaning supplies, and toxins are locked only accessible to staff.

***Narrative continues next page.****

SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Noemi Galarza
LICENSING EVALUATOR SIGNATURE: DATE: 01/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/11/2024
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, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: GRANT SERENITY ON CHARLOTTE, INC.
FACILITY NUMBER: 198603695
VISIT DATE: 01/11/2024
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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 kitchen. Pools/Jacuzzi/Body of Water & Pets: The backyard has one small water fountain. No health and safety concerns were observed. Fire Clearance: Fire clearance was approved on 9/13/23 for 6 non-ambulatory, of which 1 may be bedridden in rooms #5 or #6. Component III: Component III was waived. Applicant is presently a Licensee of other RCFE's.

The following items must be corrected and proof of correction shall be submitted to the CCLD office to the attention of LPA Galarza by 1/18/2024. If additional time is required to complete noted items to correct, then the applicant will request an extension in writing prior to the due date. Some items may require a follow up inspection for verification of correction.

1. Bedroom #1 needs window curtains that provide full privacy and bedridden rooms #5 & #6 have sliding
doors with sheer curtains that do not afford privacy. Submit picture proof evidence of corrections.

An exit interview was conducted and a copy of this report has been furnished to Nvard Gevorkian. 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: 01/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/11/2024
LIC809 (FAS) - (06/04)
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