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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195850178
Report Date: 06/27/2023
Date Signed: 06/27/2023 10:29:36 AM


Document Has Been Signed on 06/27/2023 10:29 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
Lookup Error,
, CA



FACILITY NAME:MONOGRAM VILLAFACILITY NUMBER:
195850178
ADMINISTRATOR:KRBASHYAN, AZNIV ANGELAFACILITY TYPE:
740
ADDRESS:5536 TYRONE AVETELEPHONE:
(818) 808-7792
CITY:SHERMAN OAKSSTATE: CAZIP CODE:
91401
CAPACITY:6CENSUS: 6DATE:
06/27/2023
TYPE OF VISIT:CollateralUNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Azniv Angela KrbashyanTIME COMPLETED:
10:30 AM
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Licensing Program Analyst (LPA) Evelin Rios arrived unannounced for a Collateral visit. At 9:40 a.m., the LPA met with Administrator Angela Krbashyan and explained the reason for the visit.

Today's inspection is in regard to the investigation of complaint control 31-AS-20221006122914 which is unrelated to this facility.

No health and safety concerns were observed during today's visit. Copy of Report Provided. Exit interview conducted.
SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Evelin RiosTELEPHONE: 424-299-6104
LICENSING EVALUATOR SIGNATURE:
DATE: 06/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/27/2023
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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