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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608972
Report Date: 06/24/2024
Date Signed: 06/24/2024 05:15:12 PM


Document Has Been Signed on 06/24/2024 05:15 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:ANTHEM SENIOR CAREFACILITY NUMBER:
197608972
ADMINISTRATOR:GHAZARYAN, SOFIAFACILITY TYPE:
740
ADDRESS:12813 FRIAR STREETTELEPHONE:
(818) 445-0993
CITY:NORTH HOLLYWOODSTATE: CAZIP CODE:
91606
CAPACITY:6CENSUS: 5DATE:
06/24/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:58 PM
MET WITH:Sofia Ghazaryan, AdministratorTIME COMPLETED:
05:20 PM
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Licensing Program Analyst(LPA) Christine Yee conducted an unannounced required Annual Inspection using the complete CARE Inspection Tool and met with Sofia Ghazaryan, Administrator. The reason for today's visit was provided.

The facility is a single storey family home consisting of a living room, dining room, kitchen, 5 bedrooms of which one bedroom is used for live in staff, 2 common bathrooms and 1 staff bathroom. The facility is fire cleared for 4 AMBULATORY, 1 NON-AMBULATORY and 1 BEDRIDDEN resident. Bedroom #3 is approved for bedridden use.

Due to time constraints none of the domains were reviewed on today's visit. 3 resident files were reviewed.

Based on file review:
  • Resident #1 does not have a signed medical consent form, has an incomplete Appraisal/Needs and services and inventory of valuables
  • Resident #2 has an incomplete Appraisal/Needs and Services
  • Resident #3 does not have a signed medical consent form and a incomplete Appraisal/Needs and Services.
  • The Licensee is the SSI payee for Resident #3 and the facility does not have a surety bond.



Due to time constraints, deficiencies observed on today's visit will be cited on a return visit.

Exit interview was conducted and a copy of this report was provided.
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Christine YeeTELEPHONE: (747) 230-3890
LICENSING EVALUATOR SIGNATURE:
DATE: 06/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/24/2024
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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