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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157209236
Report Date: 11/04/2022
Date Signed: 11/04/2022 12:51:44 PM


Document Has Been Signed on 11/04/2022 12:51 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:
11/04/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:24 AM
MET WITH:Grigor SedrakyanTIME COMPLETED:
01:00 PM
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On 11/04/22, Licensing Program Analyst (LPA) M. Medina conducted a subsequent announced Pre-licensing inspection. LPA met with Licensee Grigor Sedrakyan. LPA toured the facility with Licensee.

The following items have be completed: 1) No First Aid kit and first aid manual on site 2) Fire exit gate observed to be self-latching 3) Facility hot water measured at 113 degrees F 4) Facility has operating phone line with facility number to be (661) 679-7041.

Component III orientation conducted with Licensee.

LPA found that applicant has met all pre-licensing requirements. LPA will submit documentation to CAB in Sacramento for final review prior to license being issued.



Exit interview conducted. A copy of this report was provided for facility records.
SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 341-3247
LICENSING EVALUATOR NAME: Melinda MedinaTELEPHONE: (559) 410-5914
LICENSING EVALUATOR SIGNATURE:
DATE: 11/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/04/2022
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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