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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195850349
Report Date: 05/11/2023
Date Signed: 05/11/2023 12:58:28 PM


Document Has Been Signed on 05/11/2023 12:58 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, 744 P STREET, MS 9-14-8201
SACRAMENTO, CA 95814



FACILITY NAME:LOVING CARE FACILITY INC.FACILITY NUMBER:
195850349
ADMINISTRATOR:NSHANYAN, HASMIKFACILITY TYPE:
740
ADDRESS:15107 BURTON STTELEPHONE:
(310) 993-2441
CITY:PANORAMASTATE: CAZIP CODE:
91402
CAPACITY:4CENSUS: 0DATE:
05/11/2023
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
12:20 PM
MET WITH:Licensee/Administrator Hasmik NshanyanTIME COMPLETED:
12:50 PM
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Facility Type: RCFE
Application Type: Initial
Capacity: 6
Census (if any clients in care): 0
COMP II Participants: Licensee/Administrator Hasmik Nshanyan
Interview Method: Telephone interview
Virtual interview (Skype, Go To Meeting, etc)
In-person interview (Headquarter conference room)

On 5/11/2023, applicant/administrator participated in COMP II. Identification of the applicant and administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, applicant and administrator confirmed that they have read and understand community care facility licensing laws included in the Health and Safety Codes and the California Code of Regulations Title 22. Signed LIC 809 with copy of photo ID have been obtained.

During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas:
1. Facility operation: License type, client/resident populations, and program
2. Admission Policies
3. Staffing requirements & Training
4. Restrictive/Prohibited Health Conditions
5. General provisions
6. Emergency Preparedness
7. Complaints & Reporting
8. Pre-licensing readiness

New Licensees should create a Guardian account to manage their roster and assist future staff live scans without delays. To create a Guardian account, they will submit a Guardian Licensee User Access Form (LIC 9277LUA) to CDSS at GuardianLoginSupport@dss.ca.gov. A licensee/provider account will be created and CPMB will issue a new user notification email with a temporary password and link to the Guardian Agency portal. It is strongly recommended that the first step for an individual (i.e. new staff member) subject to background check should be to start the application process in Guardian rather than going directly to the Live Scan Vendor and submitting fingerprints. Proposed new staff will need to obtain an Applicant Instruction Form from the licensee which will provide a PIN code. This PIN will be required for new staff to submit an application in the Guardian system. Licensee will receive an alert of a new application to which the Licensee will choose to either ‘resume’ or ‘withdraw’. If resumed, Guardian will generate a prepopulated Live Scan form for the new staff to use when submitting their fingerprints to a Live Scan Vendor.
SUPERVISOR'S NAME: Jude De La ConcepcionTELEPHONE: (916) 651-7841
LICENSING EVALUATOR NAME: Marisa HolabirdTELEPHONE: (916) 651-9141
LICENSING EVALUATOR SIGNATURE:
DATE: 05/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/11/2023
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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