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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107201880
Report Date: 09/29/2021
Date Signed: 09/29/2021 02:29:47 PM

Document Has Been Signed on 09/29/2021 02:29 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, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:KHACHATRYAN HOMEFACILITY NUMBER:
107201880
ADMINISTRATOR:ASMIK KHACHATRYANFACILITY TYPE:
740
ADDRESS:9216 E.SHAW AVENUETELEPHONE:
(559) 299-6338
CITY:CLOVISSTATE: CAZIP CODE:
93619
CAPACITY: 9CENSUS: 3DATE:
09/29/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:35 PM
MET WITH:Staff, Nelli AgekyanTIME COMPLETED:
02:25 PM
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Licensing Program Analyst (LPA) Darius Wiliams conducted an unannounced Annual Inspection visit. LPA Williams met with Staff, Nelli Agekyan and discussed the purpose of the visit. LPA Williams spoke with Administrator, Asmik Khachtryan, via phone and discussed the purpose of the visit.

LPA Williams toured the facility with staff; 3 residents were present.

LPA Williams observed masks and disinfection station at the front entrance to the facility. Facility has one entry and exit point. Social distancing is maintained in the common areas. Hand washing and other various Covid-19 related signs were observed in the common areas.

LPA Williams observed a two day supply of perishable food and seven day supply of non-perishable food. Cleaning supplies and medication were observed behind a locked door. LPA Williams observed the following personal protective equipment in storage; gowns, masks, and gloves.

LPA Williams observed all facility staff wearing masks. 3 of 3 residents had updated emergency contact information.

LPA Williams requested the following documents be sent to the Department by 10/7/2021; personnel report (LIC 500), designation of facility responsibility (LIC 308), administrator certificate, and Covid mitigation plan (LIC 808).

No deficiencies were cited.

Exit interview was conducted and a copy of this report was provided.
SUPERVISORS NAME: Serigy Pidgirny
LICENSING EVALUATOR NAME: Darius Williams
LICENSING EVALUATOR SIGNATURE: DATE: 09/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/29/2021
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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