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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361880697
Report Date: 08/30/2023
Date Signed: 08/30/2023 10:53:24 AM

Document Has Been Signed on 08/30/2023 10:53 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
SAN BERNARDINO, 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:
08/30/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:13 AM
MET WITH:Administrator Kevin SarkisyanTIME COMPLETED:
11:00 AM
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Licensing Program Analyst (LPA) Mary Rico made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection. LPA met with Licensee Hidden Valley Assisted Living and was granted entry to the facility. The facility is a (5) bedroom, (4) bathroom home and, with a kitchen/dining area, living room and attach garage.

Physical Plant: The facility is operating in the capacity approved by Community Care Licensing (CCL). There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature. LPA inspected client bedrooms; they are equipped with required furniture such as: mattresses, night stands, storage space, and sufficient lighting; bathrooms were clean. LPA observed sufficient furniture and lighting throughout the facility. The facility is equipped with operating smoke detectors and carbon monoxide alarms.

Care & Supervision Licensee informed LPA they do not have staff, clients and are deciding to close or sell the facility. When decision is made, they will inform Community Care Licensing.

Record Review: No residents and no staff.

Based on the observations made during today’s visit, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations.

An exit interview was conducted, and this report (LIC809) was discussed and provided to Kevin K Sarkisyan.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Mary Rico
LICENSING EVALUATOR SIGNATURE: DATE: 08/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/30/2023
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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