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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603712
Report Date: 12/01/2023
Date Signed: 12/01/2023 10:45:50 AM

Document Has Been Signed on 12/01/2023 10:45 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:GRANT SERENITY OF MONROVIA, INCFACILITY NUMBER:
198603712
ADMINISTRATOR:GEVORKIAN, NVARDFACILITY TYPE:
740
ADDRESS:823 E. LEMON AVETELEPHONE:
(818) 425-6797
CITY:MONROVIASTATE: CAZIP CODE:
91016
CAPACITY: 6CENSUS: 0DATE:
12/01/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
08:36 AM
MET WITH:Nvard Gevorkian - AdministratorTIME COMPLETED:
11:00 AM
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Licensing Program Analyst (LPA) Tena Herrera conducted an announced visit and met with Administrator Nvard Gevorkian for the purpose of conducting an Initial Pre-Licensing Inspection / Component III visit.

The facility has an approved fire clearance to be licensed to serve 6 Non-Ambulatory Residents, of which 1 may be bedridden. All bedrooms are approved for bedridden.

Facility is a single-story home located in Monrovia, Ca and includes the following: 6 Bedrooms, 2 full bathrooms (one located in garage and will be used by staff only), 1 half-bathroom, living room, kitchen, dining area, 3 locked outdoor storage areas, detached garage, and a back yard with shaded outdoor patio area.

LPA toured facility inside and out alongside Administrator Nvard Gevorkian,

The Pre-Licensing Inspection Tool was utilized and the following was observed:

  • There is a locked cabinet that is centrally located for medication within the kitchen area of the facility.
  • Cleaning supplies are kept separate from food and located in a locked cabinet under the kitchen sink.
  • Facility walls, ceilings, floors, window screens and areas around the facility are clean and in good repair.
  • Fire extinguishers and smoke detectors operate properly.
  • Doors and passageways are free of obstruction.
  • There are no pools/bodies of water at the facility.
  • Facility does not have firearms on premises.
  • Facility sketch and sample menus were posted and visible within the facility.

(Continued on 809-C)
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Tena Herrera
LICENSING EVALUATOR SIGNATURE: DATE: 12/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/01/2023
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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: GRANT SERENITY OF MONROVIA, INC
FACILITY NUMBER: 198603712
VISIT DATE: 12/01/2023
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  • There is an emergency exiting plan with emergency phone numbers posted and visible within the facility.
  • Facility has a current disaster and mass casualty plan maintained.
  • There is a plan for employee accommodations and staffing arrangements.
  • Operating telephone and internet is on the premises and will be available to clients.
  • The facility does not currently have clients nor staff therefore only the Administrators file was reviewed.
  • First-aid supplies are maintained and readily available.
  • Refrigerator and freezer were observed and are maintained at the correct temperatures.
  • Food storage and preparation are clean and appropriate for food preparation.
  • Hot water temperature was tested and is within the required range of 105-120 degrees F.
  • Facility has the required posters in the facility including Personal Rights, Rights of Resident Council, Complaint Poster and Visiting Policy.
  • Facility currently does not have the required liability insurance, as insurance company needs a copy of the license before issuing needed insurance, Administrator Nvard Gevorkian confirmed that a copy of the liability insurance will be provided to LPA once license is issued and prior to admitting residents.

Component III was denied at this time as Administrator has 8 other licensed facilities and is familiar with all information within Component III.

An exit interview was conducted, and a copy of this report has been furnished to Administrator Nvard Gevorkian. 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: David Sicairos
LICENSING EVALUATOR NAME: Tena Herrera
LICENSING EVALUATOR SIGNATURE:

DATE: 12/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2023
LIC809 (FAS) - (06/04)
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