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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609523
Report Date: 12/22/2021
Date Signed: 12/22/2021 01:56:17 PM

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. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:PEACH PALACE SENIOR CARE FACILITYFACILITY NUMBER:
197609523
ADMINISTRATOR:KAVUKCHYA, ARMINEFACILITY TYPE:
740
ADDRESS:6936 PEACH AVENUETELEPHONE:
(818) 416-4242
CITY:VAN NUYSSTATE: CAZIP CODE:
91406
CAPACITY:6CENSUS: 0DATE:
12/22/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:52 PM
MET WITH:Yervand Kavukchyan - OwnerTIME COMPLETED:
01:45 PM
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Licensing Program Analyst (LPA),Brian Balisi conducted an unannounced Case Management Closure visit to the facility. LPA met with Licensee Yervand Kavukchyan and explained the reason for the visit.

On 12/20/2021, Licensee notified Regional Office (RO) the surrender of their license and the closure of the facility. During today’s visit, LPA observed facility to be vacant and verified that no care and supervision was being provided. During the facility tour of both indoor premises and the outdoor patio, LPA observed all rooms and living space areas to be empty at this time.   Licensee surrendered license to LPA.

Closure of the facility is confirmed as of this visit.
 
Exit interview conducted and a copy of the report was emailed
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian BalisiTELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:

DATE: 12/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2021
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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