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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607892
Report Date: 04/26/2023
Date Signed: 04/26/2023 03:59:19 PM

Document Has Been Signed on 04/26/2023 03:59 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:
04/26/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Gevorg MkrtchianTIME COMPLETED:
03:45 PM
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Licensing Program Analyst (LPA) Zabel Chochian arrived to this facility for a Required Annual inspection. LPA met with staff who then contacted Administrator Gevorg Mkrtchian. Reason for the visit was discussed. The facility has a central entry point for symptom screening, and temperature checks. LPA was informed that there are four (4) clients in the home at the time of visit and one (1) client was attending program. The facility serves level 3 clients from North Los Angeles County Regional Center. Two (2) staff observed during the visit. At approximately (approx.)10am to10:45am, LPA toured the facility with staff. All resident bedrooms were properly furnished with a bed, night stand, and sufficient lighting for each resident. 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 closet. LPA observed bathrooms to be clean, properly supplied with soap and paper towels/ had functional fixtures. The hot water measured in bathroom to be 110 degrees Fahrenheit. The living room and dining room were properly furnished and clean. The kitchen appeared to be clean and the appliances and fixtures functional. LPA observed sufficient amount of perishable and non-perishable food at the facility; properly stored. Sharp objects were observed locked in the kitchen cabinet. Medications and client files were observed locked in cabinets in the kitchen area as well. First aid kits properly supplied. Fire extinguisher were observed to be fully charged. Dual smoke/carbon monoxide detectors tested and functioned properly. LPA observed laundry area next to the kitchen. Cleaning supplies were observed to be locked in the cabinet.. Staff rest area accessible from laundry. LPA was informed that this area is used as office space, storage and staff break area. Emergency food supply was also observed stored in staff area. LPA did not observe any obstructions to emergency exits at this time. The facility has an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. 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. Client medications reviewed from 11am-12pm. Client and staff interviewed at approx. 2pm-2:30pm;client files including but not limited to P&I funds reviewed from approx. 2:30pm-3:15pm. Staff files reviewed at approx. 3:15pm-3:45pm. Exit interview held. Copy of report provide.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Zabel Chochian
LICENSING EVALUATOR SIGNATURE: DATE: 04/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/26/2023
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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