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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361880697
Report Date: 09/19/2024
Date Signed: 09/19/2024 01:44:26 PM

Document Has Been Signed on 09/19/2024 01:44 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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:HIDDEN VALLEY ASSISTED LIVINGFACILITY NUMBER:
361880697
ADMINISTRATOR/
DIRECTOR:		MELIKYAN, NARINEFACILITY TYPE:
740
ADDRESS:13430 HIDDEN VALLEY RDTELEPHONE:
(442) 242-7533
CITY:VICTORVILLESTATE: CAZIP CODE:
92395
CAPACITY: 6CENSUS: 0DATE:
09/19/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:45 PM
MET WITH:Ararat Sarkisyan-StaffTIME VISIT/
INSPECTION COMPLETED:
02:00 PM
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Licensing Program Analyst (LPA) Michelle Echeverria made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection.

LPA met with Staff, Ararat Sarkisyan and was granted entry to the facility. Ararat called son, Kevin Sarkisyan for communication translation. Kevin stated to LPA that the facility was closed. Kevin stated that the facility has not had residents. LPA conducted a final walk-through of the facility both inside and outside. LPA verified that there were no residents present, and there were no belongings of residents in the facility. LPA inspected the entire facility which included the bedrooms, bathrooms, dining area, kitchen, living room, family room and the backyard. Home is currently occupied by licensee and spouse. Kevin stated the reason for closure is due to no residents and do not want to go forward with being licensed.

The facility is a (5) bedrooms, (3.5) bathrooms with a kitchen, dining area, living room, family room, and attached 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 resident 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.

Record Review: No residents and no staff.

LPA informed Kevin to have Licensee, Jemma Gabrielyan send a statement letter to the regional office about the closure of the facility and license surrendered. 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 a copy of this report was discussed and provided to Ararat Sarkisyan.

SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Michelle Echeverria
LICENSING EVALUATOR SIGNATURE: DATE: 09/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/19/2024
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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