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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195850163
Report Date: 10/24/2022
Date Signed: 10/24/2022 11:54:35 AM


Document Has Been Signed on 10/24/2022 11:54 AM - 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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364



FACILITY NAME:BELLAIRE SENIOR CARE, LLCFACILITY NUMBER:
195850163
ADMINISTRATOR:ELEN KIRAKOSYANFACILITY TYPE:
740
ADDRESS:6523 BALLAIRE AVETELEPHONE:
(818) 856-6980
CITY:NORTH HOLLYWOODSTATE: CAZIP CODE:
91606
CAPACITY:6CENSUS: 6DATE:
10/24/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Ovsanna KhayalyanTIME COMPLETED:
12:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Ashley Smith conducted an unannounced Case Management- Deficiencies inspection at the facility today due to deficiencies observed during the investigation of complaint control # 29-AS-20221017131711.

Upon entry to the property, the LPA observed that the gate was not single latched. When the staff allowed the LPA on to the property, staff had to unlock the gate from the inside. This is a fire clearance violation.

Upon entry to the facility, the LPA observed three (3) smoke detectors sitting in front of the television in the living room. Staff stated that the batteries were being changed. During the walk through, the LPA noted that the smoke detector was missing from the living room and one of the resident rooms. At 11:48 a.m., the LPA observed that staff brought new batteries for the three (3) smoke detectors. Smoke detectors were checked and installed during today's visit.

The LPA spoke with licensee Davit Hakobyan at 10:56 a.m. regarding the fire clearance violation. The LPA reminded the Licensee that they had been to this facility on 8/24/2021 and they had been cited for the front gate being locked from the inside. The Licensee stated that they would change the mechanism of the lock to ensure that it was single-latch only. Mr. Hakobyan also informed the LPA that they would ensure that the smoke detectors were properly installed.

Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D):


Exit interview conducted, today's reports and appeal rights were reviewed and issued. Civil penalties issued.
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley SmithTELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:
DATE: 10/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/24/2022
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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Document Has Been Signed on 10/24/2022 11:54 AM - It Cannot Be Edited

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: BELLAIRE SENIOR CARE, LLC
FACILITY NUMBER: 195850163

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/24/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/24/2022
Section Cited

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87203 Fire Safety. All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic.
This requirement is not met as evidenced by:
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Based on observation, the licensee did not comply with the section cited above, as the entrance gate was locked from the inside of the property to the facility grounds, and three (3) smoke detectors required new batteries, which poses an immediate health and safety risk to residents in care.
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Fire clearance violation; immediate civil penalty assessed of $500

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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley SmithTELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:
DATE: 10/24/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/24/2022
LIC809 (FAS) - (06/04)
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