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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609657
Report Date: 11/04/2022
Date Signed: 11/04/2022 10:19:42 AM


Document Has Been Signed on 11/04/2022 10:19 AM - 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:HORACE ASSISTED LIVINGFACILITY NUMBER:
197609657
ADMINISTRATOR:TERZYAN, SEROBFACILITY TYPE:
740
ADDRESS:17355 HORACE STTELEPHONE:
(818) 439-8482
CITY:GRANADA HILLSSTATE: CAZIP CODE:
91344
CAPACITY:6CENSUS: 5DATE:
11/04/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Armine DishoyanTIME COMPLETED:
10:30 AM
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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 the facility staff and the administrator was called. The administrator arrived a short while later.

The LPA used the Inspection tool to conduct this visit. LPA was also able to briefly tour the home for any immediate health and safety concerns, but none were observed. The LPA was able to test the smoke alarms and carbon monoxide detectors, which all functioned properly. The fire extinguisher was observed in the kitchen and was last serviced on 5/8/2022.

No deficiencies were observed during the visit. 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: 11/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/04/2022
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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