195850089-2-1-2021-29-AS-BBAI-BXU2QE-20210201163548

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 195850089
Report Date: 02/01/2021
Date Signed: 02/01/2021 04:36:26 PM

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:	MARY ELLEN HOMES		FACILITY NUMBER:	195850089
ADMINISTRATOR:	KHACHATRYAN, GOHAR		FACILITY TYPE:	740
ADDRESS:	7752 MARY ELLEN AVENUE		TELEPHONE:	(818) 279-1415
CITY:	NORTH HOLLYWOOD	STATE: CA	ZIP CODE:	91605
CAPACITY:	6	CENSUS: 0	DATE:	02/01/2021
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	11:30 AM
MET WITH:	Gohar Khachatryan - Licensee		TIME COMPLETED:	12:30 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	A Pre licensing visit was initiated today by Licensing Program Analyst (LPA) Brian Balisi. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s pre licensing visit was conducted via Facetime at 11:30am with Licensee Gohar Khachatryan. This is a single-story residence. Fire Clearance is approved for six (6) residents. (5) non-ambulatory and (1) bedridden. Facility has (4)) bedrooms and (3) bathrooms for resident use. The physical plant was toured inside and out with Administrator. LPA observed combo Carbon Monoxide / smoke detectors throughout the facility. LPA observed fully charged fire extinguishers by the entrance, which was purchased on 11/6/2020. There was an office area located next to the living room. Resident and staff records will be stored in a locked file cabinet in this area. All rooms are set up with beds, night stands, comfortable/appropriate chairs, chest of drawers and closet space. Lighting in the rooms appeared adequate at the time of the visit. All rooms have overhead lighting. Laundry room was located by bedroom #2. LPA observed this room to be locked and stored cleaning supplies. Bathrooms are equipped with grab bars and non-skid materials. Hot water tested in the bathrooms measured between 111 - 116 degrees Fahrenheit The common areas were appropriately furnished, and lighting was adequate at the time of the visit.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Brian Balisi	TELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:	DATE: 02/01/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/01/2021

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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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: MARY ELLEN HOMES	FACILITY NUMBER: 195850089
	VISIT DATE: 02/01/2021

NARRATIVE

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Continued from 809

LPA observed kitchen knives and sharp objects stored in a locked drawer to the left of the sink. There is an adequate supply of perishable and non-perishable foods located in the fridge. LPA observed a sufficient supply of dried goods and other non-perishable items in cabinets near the fridge. The emergency food supply is kept at this location as well. The supply of dishes appeared to be adequate at this time.

Medications and first aid kit were stored in locked cabinet to the right of the fridge.

The exterior passageways were clean and clear of any obstructions. There is a shaded patio area at the back of the house and it was equipped with tables and chairs for resident use. LPA observed adequate space to conduct activities. The entire property is fenced and main gate was inaccessible from the outside.

Component III was completed in conjunction with today's visit.

Pursuant to Title 22, Division 6, facility observed to be compliant with regulation. No corrections needed at this time. A copy of this report will be forwarded to the application specialist with LPA's recommendation for licensure. A telephonic exit interview was conducted with Licensee, and a hard copy was provided via email for signature.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Brian Balisi	TELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:	DATE: 02/01/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/01/2021

LIC809 (FAS) - (06/04)

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