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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361880912
Report Date: 01/19/2024
Date Signed: 01/19/2024 11:02:44 AM

Document Has Been Signed on 01/19/2024 11:02 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:A & A CARE AND WELLNESSFACILITY NUMBER:
361880912
ADMINISTRATOR:AKOPYAN, HELENFACILITY TYPE:
740
ADDRESS:16055 SEQUOIA STREETTELEPHONE:
(818) 588-2894
CITY:HESPERIASTATE: CAZIP CODE:
92345
CAPACITY: 6CENSUS: 3DATE:
01/19/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Helen Akopyan, AdministratorTIME COMPLETED:
10:45 AM
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Licensing Program Analyst (LPA) Magda Malcore conducted an unannounced visit to the facility to follow-up on the death of resident #1 (R1). LPA met with Helen Akopyan, Administrator and discussed the purpose of the visit. The facility is a certified vendor for Inland Regional Center (IRC).

During today's visit, LPA obtained copies of pertinent documents and interviewed Administrator Akopyan for information on events leading up to the R1's death. The Administrator stated that there is no official death certificate or cause of death at this time. LPA requested the Administrator to provide Community Care Licensing Division (CCLD) Regional office with a copy of the R1's death certificate when it is available.

An exit interview was conducted where this report was discussed and a copy was provided to the Administrator as the conclusion of the visit.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Magda Malcore
LICENSING EVALUATOR SIGNATURE: DATE: 01/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/19/2024
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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