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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195850501
Report Date: 06/28/2024
Date Signed: 06/28/2024 10:36:56 AM


Document Has Been Signed on 06/28/2024 10:36 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, 744 P STREET, MS 9-14-8201
SACRAMENTO, CA 95814



FACILITY NAME:BELLAIRE SENIOR CAREFACILITY NUMBER:
195850501
ADMINISTRATOR:GEVORGYAN, EMAFACILITY TYPE:
740
ADDRESS:6523 BELLAIRE AVENUETELEPHONE:
(818) 987-1115
CITY:NORTH HOLLYWOODSTATE: CAZIP CODE:
91606
CAPACITY:6CENSUS: DATE:
06/28/2024
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Erna Gevorgyan & Eva TerzianTIME COMPLETED:
10:30 AM
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Facility Type: RCFE
Application Type: CHOW
Capacity: 6
Census (if any clients in care): 4
COMP II Participants: Erna Gevorgyan(A), Eva Terzian (C)
Interview Method: Telephone interview

On June 28, 2024, 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. Medications/Staffing requirements & Training

3.General provisions

4. Pre Licensing Inspection readiness

SUPERVISOR'S NAME: Julia KimTELEPHONE: (916) 651-7848
LICENSING EVALUATOR NAME: Dianne RamosTELEPHONE: (916) 653-5973
LICENSING EVALUATOR SIGNATURE:
DATE: 06/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/28/2024
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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