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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195850163
Report Date: 03/13/2024
Date Signed: 03/13/2024 12:22:27 PM


Document Has Been Signed on 03/13/2024 12:22 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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364



FACILITY NAME:BELLAIRE SENIOR CARE, LLCFACILITY NUMBER:
195850163
ADMINISTRATOR:ELEN KIRAKOSYANFACILITY TYPE:
740
ADDRESS:6523 BELLAIRE AVETELEPHONE:
(818) 856-6980
CITY:NORTH HOLLYWOODSTATE: CAZIP CODE:
91606
CAPACITY:6CENSUS: 4DATE:
03/13/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:42 AM
MET WITH:Erna Gevorgyan,AdministratorTIME COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA) Christine Yee conducted an unannounced case management visit to inspect the facility and to ensure the health and safety of the residents who are currently residing at the facility while the new owner of the facility obtains a license from the Department. LPA Yee was let into the home by Albert Omukulov, Staff. Erna Gervorgyan, Administrator was contacted by telephone and she arrived a little later to conduct the visit. The reason for today's visit was provided.

On today's visit, LPA Yee, inspected the food, observed the 4 residents in their rooms and toured the facility inside and outside. Per review of the food, there was perishable and non-perishable foods in the refrigerator and cabinets. However, it was not in quantities that met the minimum 2 days for perishables and a minimum to last for 7 days for non-perishables. The Applicant's spouse purchased and delivered additional perishable foods during the visit. Per the Administrator, additional non-perishable foods will be purchased today and maintained on the premises.

The facility currently has 4 residents in care. Resident #1 and Resident #2 were observed in Bedroom #2, Resident #3 in Bedroom #3 and Resident #4 in Bedroom #1. Three residents were in bed watching television and 1 was attempting to take a nap. LPA Yee observed that the residents looked clean, alert and doing well. Resident #1 and Resident #3 receive hospice services and Resident #2 and Resident #4 are waiting for doctor's orders for home health services. Upon inquiry by LPA Yee, all residents indicated that they had breakfast. Centrally stored medications were observed in a locked cupboard in the kitchen.

Per the Administrator, the facility hires 4 staff and herself. 2 staff work the day shift and 1 awake staff works the night shift and the 4th staff covers staff that are scheduled to be off.

Per tour of the inside of the facility, utilities were observed in use. Staff was preparing lunch during this visit. The inside of the facility was clean. Per tour of the outside of the facility, it was observed to be clean.
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Christine YeeTELEPHONE: (747) 230-3890
LICENSING EVALUATOR SIGNATURE:
DATE: 03/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/13/2024
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 2


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: BELLAIRE SENIOR CARE, LLC
FACILITY NUMBER: 195850163
VISIT DATE: 03/13/2024
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However, the outside areas are used for storage. Items stored in the covered back patio and along the side of the home needs to be stored or discarded. There are no bodies of water observed. Visually, there were no immediate safety hazards observed during this visit.

LPA Yee reminded Erna Gervorgyan, that while the application process is pending the facility may not accept any new admissions until the Department issues a license.


Exit interview was conducted.
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Christine YeeTELEPHONE: (747) 230-3890
LICENSING EVALUATOR SIGNATURE:

DATE: 03/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/13/2024
LIC809 (FAS) - (06/04)
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