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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107201880
Report Date: 09/28/2024
Date Signed: 09/28/2024 08:13:16 PM


Document Has Been Signed on 09/28/2024 08:13 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:
09/28/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:40 PM
MET WITH:Administrator Asmik Khachatryan vis telephoneTIME COMPLETED:
03:33 PM
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On 09/28/24, Licensing Program Analyst (LPA) L. Salazar arrived to the facility unannounced to conduct the required annual Inspection. LPA was greeted by staff, stated the purpose of the visit and was allowed entry into the facility. LPA spoke to Administrator/Licensee via telephone. Administrator on record is Asmik Khachatryan, Certificate #7003271740, Exp. 01/31/26.

LPA toured the facility inside and out. LPA observed 3 residents in care at the time of visit. Residents in care receive Regional Center services. Facility is a 5 bedroom 2 bathroom home.Facility temperature was 80 degrees F. No residents are receiving Hospice services residents or receiving Home Health care service.

Resident bedrooms were observed to have the required lighting and furnishings and were free from odor and free from any passageway obstruction / fire hazards. Bathrooms were toured and observed to have operational lights, running water, and non- slip floors. Hot water temperature tested at 111 degrees F. Trash can with lid and hand washing postings were observed. Grab bars were observed by the toilets and in the showers.

Medications were observed to be locked in a cabinet located in the hallway by the kitchen. Cleaning supplies were observed to be locked in the garage. LPA toured the kitchen observed the required 7-day supply of non-perishable food and 2- day supply of fresh perishables to be properly stored. Carbon monoxide and smoke detectors were tested and observed to be operational. Night lights were observed in the hallways. Fire Extinguisher was observed with a service date of 09/12/24. A sample of resident and staff files were reviewed and observed to have the required forms and training records.

LPA is requesting the following documents be submitted for annual updating to the Fresno CCL office by 10/11/2024: Designation of Facility Responsibility (LIC308), Administrator Organization (LIC 309), Affidavit regarding Client/Resident Cash Resources (LIC 400), Proof of Liability Insurance, Emergency and Disaster Plan (LIC 610ES) Personnel Report (LIC500), Register of Facility Clients/Residents (LIC9020A), Surety Bond.

Exit interview conducted and report was provided at the time of visit. No deficiencies cited on today's visit.
SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 341-3274
LICENSING EVALUATOR NAME: Lisa SalazarTELEPHONE: (559) 691-0004
LICENSING EVALUATOR SIGNATURE:
DATE: 09/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/28/2024
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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