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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603695
Report Date: 02/20/2026
Date Signed: 02/20/2026 04:30:40 PM

Document Has Been Signed on 02/20/2026 04:30 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 ON CHARLOTTE, INC.FACILITY NUMBER:
198603695
ADMINISTRATOR/
DIRECTOR:		KARAPETYAN, ANIFACILITY TYPE:
740
ADDRESS:5588 N.CHARLOTTE AVENUETELEPHONE:
(626) 427-1170
CITY:SAN GABRIELSTATE: CAZIP CODE:
91776
CAPACITY: 6CENSUS: 5DATE:
02/20/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:38 PM
MET WITH:Ani Karapetyan, AdministratorTIME VISIT/
INSPECTION COMPLETED:
04:35 PM
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Licensing Program Analyst (LPA) N. Galarza arrived at the facility unannounced for the purpose of conducting the Required 1-Year annual evaluation. LPA was greeted and granted entry by caregiver staff. Designee Natalia Arpentieva arrived shortly after. Administrator Ani Karapetyan arrived later on to assist with inspection. Administrator has a valid administrator's certificate expiring on 6/28/2027.

The following was observed during the inspection:

Infection Control: The facility has an Infection Control Plan.

Operational Requirements: A Dementia and hospice waiver for 3 residents has been approved. A fire clearance for 6 non-ambulatory adults 60 and over; of which one (1) may be bedridden in room 5 or 6. Facility does not handle resident P & I monies. Liability Insurance in the amount of at least ($1,000,000) per occurrence and ($3,000,000) in total annual aggregate is current with an expiration date of 7/4/2026.

Physical Plant/Environment Safety: The interior and exterior physical plant was inspected. The 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. Exit doors are free of any obstruction and there are no pools. There are 2 water fountains in the yard. Cleaning supplies and toxic substances are inaccessible to residents. The facility has two fire extinguishers. Water temperature readings measured within the required 105 - 120 degrees Fahrenheit. Electrical smoke and carbon monoxide detectors were tested and are operational. The facility maintains emergency food supply and water. Emergency Phone numbers, exit plan and programming schedules were posted. The building contains central air conditioning and heating. First aid kits/Manuals are kept in activity rooms; consisting of thermometer, tweezers, scissors, antiseptic, bandages, gauze. The last Emergency Disaster drill was conducted on 10/23/2025, not within the last three months. A citation was issued.

NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Noemi Galarza
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 02/20/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/20/2026
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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: 02/20/2026
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Staffing: A total 13 staff members provide care and supervision to the clients.

Personnel Records/Staff Training: Staff have criminal background clearance and training. Five (5) staff files were reviewed. Proof of staff training, health clearance, and 1st Aid/CPR training is current.

Resident Records/Incident Reports: A total of five (5) resident files were reviewed. They contained admission agreements, Physician's Reports, Appraisals, TB clearance, Physician's Orders, medical consent.

RCFE complaint poster and Personal rights were observed posted.

Planned Activities: Sufficient space to accommodate both indoor and outdoor activities was observed. The facility does not have a Resident Council.

Food Service: Sufficient food supply is stored in the kitchen and pantry areas consisting of: 2-day perishables, 7-day non-perishables, and emergency food supplies. Residents have modified diets.

Incident Medical and Dental: Three (3) centrally stored / 30-Day supply of medications were reviewed. Medical and dental transportation is provided by family.

Disaster Preparedness: Emergency and Disaster Plan LIC 610E was reviewed. Facility has a First Aid Kit and Manual.

Residents with Special Health Needs: One (1) resident receives hospice services and four (4) residents receive home health services. One resident is bedridden. Room 3/R1's bed had three-quarter length rail. Physician order was for half bed rail. Maintenance staff removed the rails during the visit and placed half bed rails on the bed. A citation was issued.

Pursuant to California Code of Regulations, Title 22, deficiencies were cited.



An exit interview was conducted with Administrator Ani Karapetyan. A copy of the report and appeal rights was provided.
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Noemi Galarza
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 02/20/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/20/2026
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/20/2026 04:30 PM - It Cannot Be Edited


Created By: Noemi Galarza On 02/20/2026 at 04:07 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: GRANT SERENITY ON CHARLOTTE, INC.
FACILITY NUMBER: 198603695

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/20/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87608(a)(5)(A)
Postural Supports
(A) A bed rail that extends from the head half the length of the bed and used only for assistance with mobility shall be allowed.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in that R1's bed had a three-quarter bed rail, but their physician order is for half rail only, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/20/2026
Plan of Correction
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 Maintenance staff removed the rails during the visit and placed half bed rails on the bed.
*Citation is cleared.
Type B
Section Cited
CCR
87705(k)(3)
Care of Persons with Dementia
Fire and earthquake drills shall be conducted at least once every three months on each shift and shall include, at a minimum, all direct care staff.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in that the last emergency drill was conducted on 10/23/2025, more than three months, this poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/24/2026
Plan of Correction
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Administrator agreed to submit proof that an emergency drill was conducted.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Lisa Hicks
NAME OF LICENSING PROGRAM MANAGER:
Noemi Galarza
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 02/20/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/20/2026


LIC809 (FAS) - (06/04)
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