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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850389
Report Date: 10/30/2023
Date Signed: 10/30/2023 10:33:26 AM

Document Has Been Signed on 10/30/2023 10:33 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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:GRAND SENIOR LIVING, THEFACILITY NUMBER:
565850389
ADMINISTRATOR:VERONIKA YEBEYANFACILITY TYPE:
740
ADDRESS:4752 FORT WORTH DRIVETELEPHONE:
(818) 408-9408
CITY:SIMI VALLEYSTATE: CAZIP CODE:
93063
CAPACITY: 6CENSUS: 0DATE:
10/30/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Hovsep Solakyan / Veronika YebeyanTIME COMPLETED:
10:45 AM
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Licensing Program Analyst (LPA), Martha Arroyo conducted a pre-licensing visit to this property at 9:00 a.m. on 10/30/2023 and met with Administrator Veronika Yebeyan and Licensee Representative Hovsep Solakyan. The applicant has obtained fire clearance for a total capacity of six (6) non-ambulatory residents. The facility has a dementia program in place.

LPA inspected facility for Fire Safety, Personal Accommodations and Services, and Food Service. At 9:16 a.m., all hard-wired smoke alarms and carbon monoxide detectors were tested and functioned properly. LPA observed four (4) fire extinguishers to be newly purchased on 07/28/2023.

There are six (6) single occupancy bedrooms for resident use. Each bedroom is equipped with clean mattresses, pillows, and bedding. There is a closet in the hallway with a sufficient supply of linens, including blankets, bath towels and wash cloths. Bedrooms have sufficient lighting. The facility has two (2) bathrooms for resident use. Resident bathrooms contained appropriate non-skid mats and grab bars. Bathrooms have sufficient paper products. Hot water temperature in all faucets were measured at 112 degrees Fahrenheit at the time of the visit.

LPA toured the kitchen area at 9:06 am. The facility has at least seven (7) day supply of non-perishable food and two (2) days perishable food. Appliances and all equipment appear to be clean and in good repair. Kitchen knives were observed in a locked drawer. Cleaning supplies and disinfectants will be locked under the sink inaccessible. The kitchen has a sufficient supply of plates, cups, cookware and utensils.

(Report Continued on LIC 809C...)

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Arroyo
LICENSING EVALUATOR SIGNATURE: DATE: 10/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/30/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: GRAND SENIOR LIVING, THE
FACILITY NUMBER: 565850389
VISIT DATE: 10/30/2023
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(Report Continued from LIC 809...)
The living areas and dining areas are clean and properly furnished. All window screens and coverings are in good repair. Enough seating for six (6) residents at the same time in the dining room table. A working telephone is present. There is a fireplace with adequate covering. There are activity supplies in the living room. Night-lights were present in the main hallway and common areas.

Garage: The garage is attached to the house and is locked at all times. Detergents, disinfectants, and cleaning supplies are stored and inaccessible. There will be no firearms/ammunition stored on the property. There is a sufficient supply of emergency food and water. Medications are stored in a medication cart locked inside the garage. Facility records are maintained in the garage as well. First aid kit was observed and complete with bandages, thermometer, scissors, tweezers and a current first aid manual.

The facility has required postings, including emergency exit plan, Licensing Complaint Poster, Resident Personal Rights, Theft and Loss Policy, and Resident Council Rights.

The exterior passageways were clean and clear of any obstructions. There are two (2) self-latching gates for emergency use. There were no bodies of water on the premises at the time of the visit. LPA observed the backyard, which has a covered outdoor area with a table and chairs for resident use. The washer and dryer were observed locked and inaccessible to residents in care. There is a locked shed in the backyard inaccessible.

The physical plant of this facility location is in compliance with Title 22 regulations at this time and Physical plant is consistent with the submitted facility sketch / floor plan.

Comp III conducted with the Administrator and Licensee Representative.

This report will be sent to the Centralized Application Bureau (CAB). You will be notified by the CAB Analyst when your license has been approved. You are not allowed to begin operating until you have been notified that your license has been approved by the CAB Analyst. Failure to comply could affect approval of your license.

Exit interview conducted. The report was reviewed, and a copy was provided.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Arroyo
LICENSING EVALUATOR SIGNATURE:

DATE: 10/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2023
LIC809 (FAS) - (06/04)
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