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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195850245
Report Date: 08/04/2022
Date Signed: 08/04/2022 08:42:34 PM


Document Has Been Signed on 08/04/2022 08:42 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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364



FACILITY NAME:SG CAREFACILITY NUMBER:
195850245
ADMINISTRATOR:HARUTYUNYAN, ZARUHIFACILITY TYPE:
740
ADDRESS:7920 VANTAGE AVENUETELEPHONE:
(818) 397-2656
CITY:NORTH HOLLYWOODSTATE: CAZIP CODE:
91605
CAPACITY:6CENSUS: 0DATE:
08/04/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Zaruhi HarutyunyanTIME COMPLETED:
02:30 PM
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On 08/04/2022, Licensing Program Analyst (LPA), Sandra Urena, conducted a subsequent pre-licensing visit at 1:00 p.m. The LPA met with the applicant Zaruhi Harutyunyan, and explained the reason for the visit.

On 07/15/2022, the initial pre-licensing visit was conducted by Licensing Program Analyst (LPA), Sandra Urena. The LPA arrived at the facility at 9:30 a.m., and met with the applicant Zaruhi Harutyunyan. This is a new facility application for five non-ambulatory residents, and one bedridden resident.

The following deficiencies were corrected:

1. Applicant will install smoke/carbon monoxide detector in the common area/kitchen area.
2. Add signal systems to bedroom #1 for bedridden resident, and one non-ambulatory resident; and for the four (4) non-ambulatory residents in bedrooms #2 and #3.
3. Add lock to cabinet under sink to keep cleaning supplies locked.
4. Obtain adequate flashlights for emergency, and batteries.
5. Obtain refrigerator thermometers to ensure refrigerator, and freezer temperatures are at a safe level.
6. Add a seven day supply of non-perishable food to the pantry.

This report will be sent to the Centralized Application Bureau (CAB). You will be notified by the CAB Analyst when your license has been approved. You are not allowed to begin operating until you have been notified that your license has been approved by the CAB Analyst. Failure to comply could affect approval of your license.

Exit interview was conducted and reviewed with applicant Zaruhi Harutyunyan . A copy of the report was provided.

SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra UrenaTELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:
DATE: 08/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/04/2022
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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