<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157209236
Report Date: 10/25/2022
Date Signed: 10/25/2022 12:05:47 PM


Document Has Been Signed on 10/25/2022 12:05 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:HARLOCK ASSISTED LIVING, LLCFACILITY NUMBER:
157209236
ADMINISTRATOR:SEDRAKYAN, GRIGORFACILITY TYPE:
740
ADDRESS:7214 BOUDLER FALLSTELEPHONE:
(818) 422-5898
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93312
CAPACITY:6CENSUS: 0DATE:
10/25/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:43 AM
MET WITH:Grigor SedrakyanTIME COMPLETED:
12:14 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 10/25/22, Licensing Program Analyst (LPA) M. Medina conducted an announced Pre-licensing inspection. LPA introduced self, stated the purpose of the visit, and was granted entry into the facility. LPA met with Licensee Grigor Sedrakyan. LPA toured the facility with Licensee. The facility is 4 bedrooms and 2 bathrooms home. Fire clearance was granted for 6 non-ambulatory residents.

Common areas were furnished and had adequate seating and lighting available. All bedrooms were observed to have required furnishings. Kitchen was toured and observed to have dishes, plate, and utensils. Facility has 7-day supply of non-perishable food available as of date of inspection. Kitchen has locking cabinet to secure knives and kitchen cleaning supplies. Medications will be kept in locked closet. Cleaning supplies and chemicals were observed to be in a locked in closet near laundry. Fire extinguisher present with a service date of 6/6/22. Smoke detectors and carbon monoxide detectors were observed to be operational during this inspection. Water temperature measured at 72 degrees F.

Outside of facility toured. Exits open free of obstruction. Fire exit gate is not self latching.

Component III will be conducted during follow-up facility.

The following items must be completed prior to applicant meeting all pre-licensing requirements 1) No First Aid kit and no first aid manual on site 2) Fire exit gate is not self-latching and 3) Facility no gas for hot water 4) Facility has no operating phone line.

LPA will conduct follow up inspection visit when corrections have been completed. Exit interview conducted and a copy of report provided for facility records.

SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 341-3247
LICENSING EVALUATOR NAME: Melinda MedinaTELEPHONE: (559) 410-5914
LICENSING EVALUATOR SIGNATURE:
DATE: 10/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/25/2022
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 1