195850298-1-19-2023-29-AS-SURA-CN8PY4-20230119104315

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 195850298
Report Date: 01/18/2023
Date Signed: 01/19/2023 10:44:30 AM

Document Has Been Signed on 01/19/2023 10:44 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:	LAURELGROVE BOARD AND CARE		FACILITY NUMBER:	195850298
ADMINISTRATOR:	TADEVOSYAN, LUSINE		FACILITY TYPE:	740
ADDRESS:	8221 LAURELGROVE AVE		TELEPHONE:	(818) 355-2632
CITY:	NORTH HOLLYWOOD	STATE: CA	ZIP CODE:	91605
CAPACITY:	6	CENSUS: 0	DATE:	01/18/2023
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Hrachia Martirosian		TIME COMPLETED:	02:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 01/18/2023, Licensing Program Analyst (LPA), Sandra Urena, conducted a subsequent pre-licensing visit at 1:00 p.m. The LPA met with the applicant Hrachia Martirosian, and explained the reason for the visit. On 01/10/2023, the pre-licensing visit was conducted by Licensing Program Analyst (LPA), Sandra Urena. The LPA arrived at the facility at 10:50 a.m., and met with applicant Hrachia Martirosian. This is a new facility application for a total of six residents, six (6) non-ambulatory, and one bedridden. Fire Clearance was approved on 09/16/2022 for one bedridden resident, and resident is allowed to reside in either bedroom #1 or # 2. The following deficiencies were corrected: · Bedrooms’ doors # 1, and 2 was leveled to ensure safe passage for residents to the outdoor area. · Hallway exit door needs was leveled to ensure safe passage to the outdoors. · The three-shelf apparatus with sound equipment that partially obstructs the passageway for exit was cleared. A drainage pipe sticking out at the bottom of the wall facing the bathroom, was covered. · Bedrooms # 3, 4, and 5 were observed with a bed, mattress, pillows and bedding/linens. Bedroom #1 was found to have two beds with linens. · Toilets were equipped with adjustable handlebars/Safety toilet rails. · Door leading to bedrooms # 3, 4, and 5 were equipped with a magnet device to keep it open. Door leading to bedroom #2 was equipped with a magnet to keep it open.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra Urena	TELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:	DATE: 01/18/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/18/2023

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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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: LAURELGROVE BOARD AND CARE	FACILITY NUMBER: 195850298
	VISIT DATE: 01/18/2023

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An operating land line telephone was observed at the time of the visit.

· A padlock was installed to make the body of water inaccessible to residents.
· Passage leading from bedroom #1 to backyard area was leveled to ensure safe passage for resident from patio to backyard area.

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 Hrachia Martirosian. A copy of the report was
issued.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra Urena	TELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:	DATE: 01/18/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/18/2023

LIC809 (FAS) - (06/04)

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