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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425850225
Report Date: 12/09/2021
Date Signed: 12/09/2021 01:44:36 PM

Document Has Been Signed on 12/09/2021 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
CCLD Regional Office, 744 P STREET, MS 9-14-8201
SACRAMENTO, CA 95814
FACILITY NAME:FAMILY CONNECT MEMORY CARE SOLVANGFACILITY NUMBER:
425850225
ADMINISTRATOR:MAHAKIAN, LAURENFACILITY TYPE:
740
ADDRESS:659 CHALK HILL ROADTELEPHONE:
(310) 383-1877
CITY:SOLVANGSTATE: CAZIP CODE:
93463
CAPACITY: 6CENSUS: DATE:
12/09/2021
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Lauren Mahakian & Vatche KhedesianTIME COMPLETED:
01:35 PM
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Facility Type: RCFE
Application Type: Initial
Capacity: 6
Census (if any clients in care): zero
Method: Telephone call with CAB
COMP II Participants: Lauren Mahakian & Vatche Khedesian

Applicant/administrator participated in COMP II via telephone call with the analyst at CAB. Identification of the applicant and administrator was verified by photo ID. During COMP II, applicant and administrator confirmed the understanding of Title 22. Component II was successfully completed. Applicant has been advised to transmit signed LIC 809 with copy of photo ID to CAB.
SUPERVISORS NAME: Julia Kim
LICENSING EVALUATOR NAME: Dianne Ramos
LICENSING EVALUATOR SIGNATURE: DATE: 12/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/09/2021
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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