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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608215
Report Date: 12/07/2023
Date Signed: 12/07/2023 01:36:43 PM

Document Has Been Signed on 12/07/2023 01:36 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 S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:PACOIMA ADCFACILITY NUMBER:
197608215
ADMINISTRATOR:VERJINE EGIANFACILITY TYPE:
775
ADDRESS:13117 VAN NUYS BLVDTELEPHONE:
(818) 434-0004
CITY:PACOIMASTATE: CAZIP CODE:
91331
CAPACITY: 90CENSUS: 47DATE:
12/07/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Verijine EgianTIME COMPLETED:
01:35 PM
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Licensing Program Analyst (LPA Christopher Alemoh, met with Verijine Egian (Program Director/Administrator) for an annual visit at 08:30 am. LPA arrived and were greeted by staff and clients participating in day program services. Administrator took temperature and LPA signed visitor’s sheet. Entrance interview conducted. The facility has COVID-19 and hand washing signs; Posted throughout the facility.

At the time of visit the facility Census is 47.

At 08:50 am LPA toured the physical plant with Director Verijine Egian, to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations.

Common Activity Space: The facility is a Day Program which operates from 8:30 am to 4:30 PM.
LPA observed there to be one large open area in which program activities are provided. This area consists of tables, chairs, sofas, a kitchen, television and board games for client use. Furniture used is in good repair. LPA did not observe any obstructions or hazards. All equipment used for activities appears to be in adequate condition.
Three (3) fire extinguishers observe throughout the facility the charge date is April 4th 2023. Smoke Alarm/Carbon monoxide detector are hardwired and operational. Fire inspection was completed by the Los Angeles Fire Department and was found to be in compliance with Fire Code Regulations at the time of inspection.
Facility temperature is kept at 67 degrees Fahrenheit. No bodies of water.

Fire and earthquake drills conducted within the last 6 months were on June 2nd 2023 as per regulation.
LPA observed staff actively working with consumers.
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Christopher Alemoh
LICENSING EVALUATOR SIGNATURE: DATE: 12/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/07/2023
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 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: PACOIMA ADC
FACILITY NUMBER: 197608215
VISIT DATE: 12/07/2023
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(Contd. from 809)

Medication: Clients medication to be stored in locked cabinet in assistant administrator’s office. The first aid kit located in administrator’s office. The three (3) fire extinguishers observed with current receipt attached.


Food Service: LPA inspected the kitchenette area and observed the hazardous material and kitchen equipment to be locked. There is a small kitchenette with a sink. There is a refrigerator which keep consumer lunches cold. Consumers also hot lunch from a food delivery service.
Restroom: LPA inspected restrooms. Restrooms were clean. Trash cans have lids to protect consumers from cross contamination. The hot water temperature in the men’s bathroom was tested, and measured at 118.7 degrees F.

File Review: LPA conducted a file review of all 8 Staff members, each staff file had all proper and dated documentation. LPA reviewed 10 percent of client population. LPA observed all client documents to be complete and dated.

No deficiencies cited.

An exit interview was conducted. A copy of this report and appeal rights were discussed and left with Administrator Verijine Egian.

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Christopher Alemoh
LICENSING EVALUATOR SIGNATURE:

DATE: 12/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/07/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2