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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609003
Report Date: 11/07/2023
Date Signed: 11/07/2023 02:34:16 PM

Document Has Been Signed on 11/07/2023 02:34 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: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:
11/07/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:33 AM
MET WITH:YERANUHI GHAZARYANTIME COMPLETED:
02:30 PM
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On 11/7/23 at around 9:30 AM, Licensing Program Analyst (LPA) Christopher Alemoh conducted an unannounced Required – 1 Year Inspection at ABEL&DAVIT HAYRAPETYAN'S COMMUNITY CARE FACILITY and was greeted by DSP Catherine Wayro. LPA explained the purpose of the visit and was accompanied by Carolyn Wayro inside and outside the facility during this inspection. DSP Wayro checked LPA Alemoh’s temperature upon entry to the facility.

Facility temp measured at 71 degrees The facility consists of 4 client bedrooms, 1 staff bedroom, 2 bathrooms, a living room, dining room, laundry room and kitchen.

This facility is licensed to serve 4 adults ages 18 – 59 years. A total of 4 clients are currently residing in this facility, 4 out of 4 clients are ambulatory. A total of 1 staff and no clients were present during this inspection.

Outside grounds were toured and no bodies of water were observed. Patio furniture under a shaded area was accessible to clients. Walkways around the home were clear of hazards. There are no security bars or weapons on the premises. Facility has converted garage to administrator office/ Laundry room. Washer and dryer in good working condition. Chemicals and washing liquids are secured over washer and dryer. Facility has a second fridge in the Administrator office. This area of the facility is not accessible to residents.

In the kitchen dishes, cups and flat ware are stored in the kitchen cupboards, inspected and in good repair. Knives, cutlery and other sharp kitchen utensils are stored in a locked over the refrigerator. Food supply adequate stored in the pantry in the garage. and consists of perishable and nonperishable food and dining ware to accommodate all residents. Dishwasher in kitchen properly installed and functioning. Stove burners, oven, microwave, washer, and dryer working. There are two refrigerators in the home, one in the kitchen and one in the garage for additional food storage. Each refrigerator has a measured temperature of at least 45 degrees Fahrenheit for appropriate food storage. Freezer is at (0) zero degrees Fahrenheit. Kitchen water temp tested at ­­115 degrees.

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Christopher Alemoh
LICENSING EVALUATOR SIGNATURE: DATE: 11/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/07/2023
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: ABEL&DAVIT HAYRAPETYAN'S COMMUNITY CARE FACILITY
FACILITY NUMBER: 197609003
VISIT DATE: 11/07/2023
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(Cont. from 809)

4 out of 4 client’s bedrooms were checked. Mattresses were in good condition, adequate lighting, plenty of dresser and closet space observed. Walls and floors were clean and in good condition. Comforters, bed linen, bath towels and mattress protectors were adequately stocked. Bathroom toilets and water faucets worked properly. Adequate lighting and toiletries accessible to clients. LPA Alemoh tested hot water temperature in the middle hallway client restroom, and it measured between 114- and 115.1-degrees Fahrenheit. This facility provides clients with residents with hygiene products such as feminine napkins, nonmedicated soap, toilet paper, toothbrush, toothpaste, and comb.

LPA observed that Medications were safe, locked and inaccessible. All medications observed were labeled and maintained in compliance with label instructions and State and Federal law. All Medication are stored in a closet adjacent to the front door. Documents are posted as mandated. Last Disaster drill was conducted on 10/29/23. First aid kit is fully stocked with manual. Smoke and carbon monoxide detectors are hardwired and in compliance and operational. One (1) Fire Extinguisher observed in the kitchen purchase date is February 2nd, 2023.


Five (5) staff records were reviewed, 5 out of 5 staff records had current first aid certificates and had required criminal record clearances or criminal record exemptions. Four (4) client records were reviewed and, 4 out of 4 client records had Admission Agreements, Medical Assessments, Pre-appraisals (or Reappraisals) and/or Needs & Services Plans. LPA Alemoh reviewed P&I money, 4 out of 4 residents P&I were intact and were not commingled with facility funds or petty cash. All client/resident and staff files are locked in small rolling cabinet in the dining room inaccessible to residents.

No deficiencies cited.

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

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

DATE: 11/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2023
LIC809 (FAS) - (06/04)
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