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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609633
Report Date: 09/14/2022
Date Signed: 09/14/2022 12:16:23 PM


Document Has Been Signed on 09/14/2022 12:16 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:ORCHID LIVING BOARD AND CARE INCFACILITY NUMBER:
197609633
ADMINISTRATOR:PETROSYAN, ANNAFACILITY TYPE:
740
ADDRESS:16729 TULSA STREETTELEPHONE:
(747) 239-3219
CITY:GRANADA HILLSSTATE: CAZIP CODE:
91344
CAPACITY:6CENSUS: DATE:
09/14/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Florence PelegrinoTIME COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA), Patrick Shanahan, Arrived at the facility in order to conduct an infection control annual. The LPA was greeted by facility staff and had his temperature taken and covid 19 questions asked before being allowed entry.

The Infection Control tool was used to conduct this visit. LPA was able to test the carbon monoxide detector and the smoke alarms and they all functioned properly. The fire extinguisher also appeared functional.

The facility is currently following their infection control plan.

Exit interview conducted and report issued
SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Patrick ShanahanTELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:
DATE: 09/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/14/2022
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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