197609731-10-8-2024-31-AS-LNCA-D9UNG3-20241008102627

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609731
Report Date: 10/08/2024
Date Signed: 10/08/2024 10:26:45 AM

Document Has Been Signed on 10/08/2024 10:26 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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	G & A CARE		FACILITY NUMBER:	197609731
ADMINISTRATOR:	KOSOYAN, GRIGOR		FACILITY TYPE:	740
ADDRESS:	16301 NORDHOFF STREET		TELEPHONE:	(323) 314-2996
CITY:	NORTH HILLS	STATE: CA	ZIP CODE:	91343
CAPACITY:	6	CENSUS: 2	DATE:	10/08/2024
TYPE OF VISIT:	POC	UNANNOUNCED	TIME BEGAN:	09:23 AM
MET WITH:	KOSOYAN, GRIGOR- Licensee		TIME COMPLETED:	11:00 AM

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Licensing Program Analysts (LPA) Leslie Ngo-Castaneda met with facility licensee Grigor Kosoyan for a Plan Of Correction (POC) visit.

The purpose of the POC visit is to make sure deficiencies were corrected on reports issued on 9.17.2024.

Entrance interview conducted.

LPA toured the home and requested the following:

-CCR 87465(h)(1)(C), 87465(i), and 87465(h)(2): Incidental Medical and Dental Care Services:

POC: Licensee needs to ensure that medications are not accessible and needs to be kept locked. Expired medication needs to be dispose or return to the family when they leave the facility.

POC date 10.8.2024: POC Cleared during LPA visit.

- CCR 87309(a); 87465(i) and 87303(e)(5):Physical Plant/Environmental Safety:

POC: Licensee needs to ensure that chemicals and cleaning supplies needs to be kept locked at all times. Licensee needs destroy left over medication of those three residents. Licensee needs to purchase a new non-skid mat for the bathroom.

POC date 10.8.2024: POC Cleared during LPA visit.

Continue to LIC 809-C

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4370
LICENSING EVALUATOR NAME: Leslie Ngo-Castaneda	TELEPHONE: (818) 214-9900
LICENSING EVALUATOR SIGNATURE:	DATE: 10/08/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/08/2024

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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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: G & A CARE	FACILITY NUMBER: 197609731
	VISIT DATE: 10/08/2024

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- CCR 87211(a)(1)(A): Reporting Requirement:

POC: Administrator agreed to submit death reports for any residents.

POC date 10.8.2024: POC Cleared during LPA visit.

- CCR 87413(a)(1) and 87411(a): Personnel Requirements - General

POC: Licensee needs to have a staff when they licensee leaves the facility.

POC date 10.8.2024: POC Cleared during LPA visit.

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4370
LICENSING EVALUATOR NAME: Leslie Ngo-Castaneda	TELEPHONE: (818) 214-9900
LICENSING EVALUATOR SIGNATURE:	DATE: 10/08/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/08/2024

LIC809 (FAS) - (06/04)

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