<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608215
Report Date: 07/31/2024
Date Signed: 07/31/2024 03:59:04 PM

Document Has Been Signed on 07/31/2024 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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:PACOIMA ADCFACILITY NUMBER:
197608215
ADMINISTRATOR/
DIRECTOR:		VERJINE EGIANFACILITY TYPE:
775
ADDRESS:13117 VAN NUYS BLVDTELEPHONE:
(818) 434-0004
CITY:PACOIMASTATE: CAZIP CODE:
91331
CAPACITY: 90CENSUS: 41DATE:
07/31/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:15 AM
MET WITH:Verjine Egian, DirectorTIME VISIT/
INSPECTION COMPLETED:
03:00 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Leizl de la Cerra conducted an unannounced required 1-yr inspection. LPA was allowed entry by Verjine Egian, facility director at 11:00am and explained the purpose of the visit. The program is vendorized through the North Los Angeles County Regional Center and Frank D. Lanterman Regional Center. It is licensed to serve 90 developmentally disabled, ages 18 and above. The program hours are 08:00AM - 5:00PM.
LPA de la Cerra inspected the entire facility which included, but not limited to the front reception area, program rooms, program offices, kitchen, bathrooms and outside perimeters of the facility. Additionally, LPA reviewed a total of three (3) client record files and four (4) personnel record files including facility administrative file from 11:30AM to 3:00PM.
The facility is a single story structure, with its own parking lot in the back alley. The facility consists of a large space with 5 separate table set-up that are designated for different activities, there is a reception area, two offices, one quiet room, one computer room, a gym, one locked storage room, kitchen area, a living room area with comfortable sitting area and a television set, two bathrooms which is separated by men's bathroom and women's bathroom. and a shaded patio area.
The kitchen area was observed by LPA, food preparation area to be clean. The cleaning solutions are locked in a cabinet underneath the sink. The knives and and other sharp objects are observed to be locked in an upper cabinet. The trash bin is observed to have a tight fitting cover. The clients are served breakfast at the facility and provided by a catered lunch.

-Continued to LIC 809C
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Leizl De La Cerra
LICENSING EVALUATOR SIGNATURE: DATE: 07/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/31/2024
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 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: 07/31/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
There are two (2) bathrooms: one designated for men and one designated for women. LPA observed all bathrooms to have grab bars, paper towels and trash cans. The hot water measured to 110.3 degrees Fahrenheit.

The facility fire clearance is maintained by Los Angeles Fire Department with inspection date of 4-23-2024.


There are three (3) available fire extinguishers observed with inspection date of 4/10/2024.

Facility maintains a comfortable temperature of 73 degrees Fahrenheit.

The first aid kit located in administrator’s office and LPA observed first aid kit and first aid manual to be current and complete.

Personnel staff files and client files are observed to be in a locked cabinet inside the administrator's office. Clients medication observed to be stored and locked in a 2 drawer cabinet in the administrator’s office.

No deficiencies cited. An exit interview was conducted, and a copy of this report was provided to the facility director.

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Leizl De La Cerra
LICENSING EVALUATOR SIGNATURE:

DATE: 07/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/31/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2