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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195850163
Report Date: 04/16/2024
Date Signed: 04/16/2024 02:09:16 PM


Document Has Been Signed on 04/16/2024 02:09 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:
04/16/2024
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
12:40 PM
MET WITH:Erna Gevorgyan, AdministratorTIME COMPLETED:
02:15 PM
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Licensing Program Analyst(LPA), Christine Yee conducted an unannounced case management visit to check on the health and safety of the 4 residents in care. LPA Yee was let into the home by Albert Omurkulov, Staff. Erna Gevorgyan, Administrator was contacted by Staff and she arrived at 12:55pm to conduct the visit. The reason for today's visit was explained.

LPA Yee conducted an interview with the Administrator to determine if there were any changes to the residents condition, concerns with services and medications that would impact the resident's health and safety. Per information provided, there have no changes to any of the residents condition or services. The only issue that the home had was with Resident #4's medication refill on 4/4/24 due to the pharmacy being switched to the one used by the home health doctor. Resident #4 had sufficient medications up until 4/14/24 and received the medication refills on 4/15/24 and there was no lapse or missed medications.

Per observation of the residents, all the residents were observed to be alert and in bed watching television. All the residents had finished lunch prior to this visit. Resident #1- Resident 3 were observed snacking on sliced apples.

Food supply was reviewed and there were sufficient perishable and non-perishable foods were observed for 4 residents. Bananas, apples and oranges were observed on the kitchen counter.

Per tour of the home, the inside was observed to be clean and utilities were in use. The outside areas were also clean. No immediate safety concerns were observed on this visit.

Exit interview was conducted.
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Christine YeeTELEPHONE: (747) 230-3890
LICENSING EVALUATOR SIGNATURE:
DATE: 04/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/16/2024
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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