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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361880697
Report Date: 08/12/2021
Date Signed: 08/12/2021 11:25:42 AM

Document Has Been Signed on 08/12/2021 11:25 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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:HIDDEN VALLEY ASSISTED LIVINGFACILITY NUMBER:
361880697
ADMINISTRATOR:MELIKYAN, NARINEFACILITY TYPE:
740
ADDRESS:13430 HIDDEN VALLEY RDTELEPHONE:
(442) 242-7533
CITY:VICTORVILLESTATE: CAZIP CODE:
92395
CAPACITY: 6CENSUS: 0DATE:
08/12/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:53 AM
MET WITH:Ararat SarkisyanTIME COMPLETED:
11:40 AM
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Licensing Program Analysts (LPAs) Melody Brown and Natalie Gayoso made an unannounced visit to conduct an annual inspection, with emphasis on infection control. Upon arrival, LPAs met with homeowner Ararat Sarkisyan and discussed the purpose of todays visit. Mr. Sarkisyan called Administrator Kevin Sarkisyan who stated he was not available and there are no clients in care at this time.

LPAs were informed by the Administrator that the facility does not have any residents due to Covid-19 pandemic and it's hard to find caregivers. The Administrator stated that he wishes to remain licensed.

LPAs inspected the inside and outside of the facility and verified there are no residents in care. LPAs toured the bedrooms, the bathrooms and checked food supply. The Administrator was instructed to informed the LPA Gayoso when the first resident is placed at the facility.

An exit interview was conducted and a copy of this report was provided to Mr. Ararat Sarkisyan.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE: DATE: 08/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/12/2021
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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