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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195850507
Report Date: 10/10/2024
Date Signed: 10/10/2024 04:44:02 PM

Document Has Been Signed on 10/10/2024 04:44 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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:S & S ADULT RESIDENTIAL FACILITY INCFACILITY NUMBER:
195850507
ADMINISTRATOR/
DIRECTOR:		GHAZARYAN, YERANUHIFACILITY TYPE:
735
ADDRESS:6458 RADFORD AVETELEPHONE:
(323) 219-5454
CITY:NORTH HOLLYWOODSTATE: CAZIP CODE:
91606
CAPACITY: 4CENSUS: 0DATE:
10/10/2024
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:49 AM
MET WITH:Yeranuhi Ghazaryan, AdministratorTIME VISIT/
INSPECTION COMPLETED:
04:50 PM
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Licensing Program Analyst (LPA) Christine Yee conducted an announced Prelicensing and Component III visit to ensure that the home meets Title 22 requirements. The CARE Inspection Tool was used during the visit. LPA Yee met with Yeranuhi Ghazaryan, Co-Licensee/Administrator. Also present during today's visit was Lilit Movsisyan, Co-Licensee/CEO.

The facility is a single storey family home consisting of a living room, dining room, kitchen, 5 bedrooms of which one is used as an office, 3 full bathrooms and a detached garage. The facility is fire cleared for 4 AMBULATORY clients only. The facility is also in the process of being vendorized by the North Los Angeles County Regional Center as a Level 3 home.
The following were observed on today's visit:
  • the living room is furnished with 2 love seats, a coffee table and a side board and television
  • the dining room is furnished with a dining room table with 6 chairs
  • the kitchen is equipped with a refrigerator, a stove and a microwave. Sufficient plates, cups, bowls drinking glasses, pots and pans , knives, forks, dinner spoons and tea spoons were observed. Sharp knives are stored in a locked cabinet above the stove and cleaning and disinfecting solutions stored in a locked cabinet under the sink.
  • sufficient perishable and non-perishable foods were observed.
  • Medications, staff and client files will be stored in the locked cupboard by the dining room
  • Bedrooms #1, #2, and #3 were furnished with a full size bed, a night stand, a lamp, a chair, a dresser and has a built in closet. Blinds were observed to be in good condition.
  • Bedroom #4 is also furnished with a full size bed, night stand, a chair, a lamp and a portable closet but does not have a dresser.
  • the bedroom located at the back left side of the home is used as an office. The room has a direct exit to the outside.
continued on LIC809-C Page 2
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Christine Yee
LICENSING EVALUATOR SIGNATURE: DATE: 10/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/10/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: S & S ADULT RESIDENTIAL FACILITY INC
FACILITY NUMBER: 195850507
VISIT DATE: 10/10/2024
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  • The required bed linens were observed on all the beds and an extra set was observed in the residents' dresser. Extra bed linens are stored in the office closet.
  • 2 sets of towels were also observed in the residents' dressers
  • hygiene products such as shampoos, toothpaste, toothbrush, wipes were observed in the bedrooms
  • All 3 common bathrooms are equipped with a bath tub and shower, a toilet and a sink. Non-skid mats were observed in the tubs. There were no grab bars observed. The trash cans were tightly sealed. The water temperature was taken in all 3 bathrooms and the following readings were obtained: the water temperature in the bathroom located by the living room read 120.7 degrees, the water temperature in the bathroom located by laundry area read 121.4 degrees and the water temperature in the bathroom located by the office read 122.7 degrees Fahrenheit..
  • the facility has a washer and dryer in the resident hallway and laundry detergent are locked in a cabinet above the washer and dryer.
  • The facility has a land line - telephone # (747)205-2017
  • the facility has a total of 4 fire extinguishers and are located in the following rooms: kitchen, living room, laundry room and by the front bathroom. All 4 fire extinguishers were purchased on 10/9/24.
  • No night lights were observed in hallway. Per Administrator they plan to live the hall light on.
  • a first aid kit containing the required Title 22 -scissors, thermometer, tweezer was observed. No first aid manual was observed.
  • Posters were observed but no Labor Poster was noted.
  • the hardwired combination smoke/carbon monoxide detectors were tested and were operational on today's visit.
  • The facility has a surety bond in the amount of $6,000.00. General liability and workers compensation insurance will be purchased when licensed is issued.
  • Per tour of the backyard, a table with 4 chairs and an umbrella was observed.
  • The detached garage was observed to be used for storage and per fire clearance, the garage must be used as a garage. Licensee will remove stored furniture and other items.
  • The backyard and front yard needs to have dried weeds mowed and general cleaning performed.
  • the trash cans located in the front were stuffed with trash and were not tightly sealed.

continued on LIC809-C Page 3
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Christine Yee
LICENSING EVALUATOR SIGNATURE:

DATE: 10/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2024
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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: S & S ADULT RESIDENTIAL FACILITY INC
FACILITY NUMBER: 195850507
VISIT DATE: 10/10/2024
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 The following corrections need to be made prior to licensure:
  • a first aid manual needs to be purchased
  • purchase and post labor poster
  • provide a dresser meeting Title 22 requirements of 8 cubic feet for bedroom #4
  • adjust the thermostat to ensure that the water temperature is within 105-120 degrees Fahrenheit.
  • mow the dry weeds, and trim the trees in the front and backyard and conduct general cleaning.
  • discard the trash and ensure that all trash cans are tightly sealed
  • clean out the items stored in the garage
  • remove all personal belongings from bedroom #1 and personal hygiene products from the bathroom located by the office.

Component III was conducted with Yeranuhi Ghazaryan, Co-Licensee/Administrator.


Applicant will notify LPA Yee that the corrections were completed and provide evidence of the corrections.
Once corrections have been approved, LPA Yee will send notification to the CAB Analyst to proceed.

Exit interview was conducted.

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Christine Yee
LICENSING EVALUATOR SIGNATURE:

DATE: 10/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2024
LIC809 (FAS) - (06/04)
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