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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607892
Report Date: 04/04/2022
Date Signed: 04/04/2022 02:47:39 PM

Document Has Been Signed on 04/04/2022 02:47 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:CHRISTINE'S RETREATFACILITY NUMBER:
197607892
ADMINISTRATOR:GEVORG MKRTCHIANFACILITY TYPE:
735
ADDRESS:14712 KILLION STREETTELEPHONE:
(818) 387-8572
CITY:SHERMAN OAKSSTATE: CAZIP CODE:
91411
CAPACITY: 6CENSUS: 5DATE:
04/04/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Gevorge Mkrtchian - AdministratorTIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Brian Balisi arrived to this facility today to conduct a One (1) year Required inspection of this facility with emphasis on infection control practices and procedures. LPA met with
Administrator Gevorge Mkrtchian and explained the reason for the visit. At Approx. 12:30pm, LPA observed (4) clients watching television in the living room. (1) client was in program at this time.

The facility serves clients from North Los Angeles County Regional Center. Potentially dangerous items are kept inaccessible to clients with developmental disabilities and intellectual disabilities. There is staff to meet the needs of clients with developmental disabilities and intellectual disabilities.

At approx 12:45pm, LPA toured the facility with Administrator. The kitchen appeared to be clean at this time and the appliances and fixtures functional during the time of visit. LPA observed a sufficient amount of perishable and non-perishable food at the facility; properly stored. Sharp objects were observed stored in the cabinet to the right of the fridge. LPA observed cabinet to be locked at this time. Dining room furniture appeared to be relatively clean and functional at this time.



The resident bedrooms were properly furnished with a bed, night stand, and sufficient lighting for each resident. LPA observed PPE supplies for each client in their bedrooms. The bedrooms had appropriate and adequate bedding and linens such as sheets, pillowcases, mattress pads, and blankets. LPA observed a sufficient supply of linen and personal hygiene supplies in the hallway closet nearest to bedroom #1.

LPA observed all bathrooms were clean, properly supplied and had functional fixtures. The hot water was measured in each bathroom between 105 - 120 degrees Fahrenheit.

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SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE: DATE: 04/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/04/2022
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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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: CHRISTINE'S RETREAT
FACILITY NUMBER: 197607892
VISIT DATE: 04/04/2022
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Continued from 809-C

Common Areas: These included the living room and dining room. The common areas were checked for cleanliness and furniture was checked for functionality during time of visit. Dining room furniture appeared to be relatively clean and functional at this time. Medications were observed stored in the locked cabinet to the right of the fridge. Client files were observed locked in cabinets in this area as well. LPA observed first aid kits properly supplied in the cabinet to the right of the fridge. Fire extinguisher were observed to be fully charged, but needing service. Administrator shared communication with LPA that service was scheduled to be conducted by end of business today. LPA observed a 30 day supply of PPE stored in desk in dining area. LPA observed laundry area next to the kitchen. Cleaning supplies were observed to be locked in the cabinet to the right of the washing machine. Staff rest area accessible from laundry. LPA observed area to be empty at this time of visit. Administrator stated staff only rest in this area at this time.

Outdoor Area: There was a shaded area with sufficient room for activities. LPA observed sufficient furniture designated for outdoor use. There are no bodies of water on the premises. LPA observed a sufficient amount of space for activities. Emergency food supply was stored in staff area. LPA did not observe any obstructions to emergency exits at this time.

The LPA spoke with Gevorge regarding the facility’s infection control practices. Upon entry, the facility has a central entry point for symptom screening, temperature checks, and sanitation station. The facility has an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate the master bedroom as a single isolation room if the facility has a confirmed case of COVID-19. COVID-19 testing is conducted weekly if there are any covid-19 concerns. The facility’s policies and procedures as it pertains to infection control are adequate at this time.

Exit interview conducted. Report issued and sent via email.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:

DATE: 04/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/04/2022
LIC809 (FAS) - (06/04)
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