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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609003
Report Date: 02/15/2022
Date Signed: 02/15/2022 04:45:17 PM

Document Has Been Signed on 02/15/2022 04:45 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., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:ABEL&DAVIT HAYRAPETYAN'S COMMUNITY CARE FACILITYFACILITY NUMBER:
197609003
ADMINISTRATOR:GHAZARYAN, YERANUHIFACILITY TYPE:
735
ADDRESS:10185 SHARP AVETELEPHONE:
(323) 219-5454
CITY:ARLETASTATE: CAZIP CODE:
91331
CAPACITY: 4CENSUS: 4DATE:
02/15/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:40 AM
MET WITH: YERANUHI GHAZARYAN TIME COMPLETED:
03:28 PM
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Licensing Program Analyst (LPA) Tihesha “Lynn” Smith conducted an unannouced Annual Required visit to this facility. LPA was greeted by facility staff, Catherine Wayro, who was observed wearing a mask and took LPA's temperature upon entry and Covid symptoms questions contained on a separate form. LPA explained the reason for the visit. Administrator Yeranuhi Ghazaryan was called at 10:38 am and arrived after.

LPA conducted a tour at 12:45 PM of the physical plant to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations The facility has working interconnected smoke alarms and carbon monoxide alarms that are hard wired and battery operated. All smoke alarms were tested and function properly. The carbon monoxide detector was tested and functions properly. The fire extinguisher was current with receipt.

Staff confirmed there are four (4) ambulatory residents residing in facility. The living area had sufficient lighting, adequate seating, was clean and properly furnished.

The kitchen appeared clean, the appliances and fixtures were functional. The kitchen food supply was observed and sufficient for the four (4) clients currently residing there. Two (2) days of perishable fruits, vegetables, milk and eggs observed with juice. The freezer is stocked with meats and frozen vegetables. There is also a second refrigerator and pantry in a converted garage stocked with additional perishable and non-perishable food, canned goods, water and PPEs. The sharps are locked in a cabinet above the refrigerator in the kitchen. The cleaning supplies were locked in the cabinet under the kitchen sink.
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Tihesha Smith
LICENSING EVALUATOR SIGNATURE: DATE: 02/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/15/2022
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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: ABEL&DAVIT HAYRAPETYAN'S COMMUNITY CARE FACILITY
FACILITY NUMBER: 197609003
VISIT DATE: 02/15/2022
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(Cont From 809)

A tour of the resident bedrooms, bathrooms, personal accommodations, and common areas (all resident
bedrooms toured had the required furniture for residents’ comfort and safety). Common areas were observed for the ability to safely serve the needs of residents, including cleanliness, locks, skid materials, and comfortable temperatures. LPA observed a sufficient supply of linen, hygiene backstock, and PPEs in the hall closet.

There are two bathrooms which contain “wash your hands” sign, hand soap, paper towels, and trash cans. The hot water temperature was measured for two (2) bathrooms to ensure it is within the required range for residents’ comfort and safety. The water temperature range was between 110.7- and 113.1-degrees Fahrenheit.

The resident’s medications and first aid kits locked in a file cabinet in a locked closet next to the front door. LPA checked first aid kit and the first aid kit has sufficient supplies including a


backup first aid kit.

Surrounding Grounds: There is a shaded area with furniture appropriate for outdoor use. All passageways are free of obstruction. The laundry area is in a converted garage to office area behind the facility. Laundry supplies are kept in a locked cabinet next the washing machine.

LPA reviewed files for the four (4) residing residents. All resident files included current medical assessments, physician orders for medications and centrally stored medication logs. Staff files were also inspected. All staff files inspected had current First aid/CPR documentation. Medications are given as prescribed.

No Deficiencies cited. Exit interview conducted and printed.

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Tihesha Smith
LICENSING EVALUATOR SIGNATURE:

DATE: 02/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2022
LIC809 (FAS) - (06/04)
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