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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609748
Report Date: 05/19/2021
Date Signed: 05/19/2021 03:48:49 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., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:GRANADA GOLDEN YEARSFACILITY NUMBER:
197609748
ADMINISTRATOR:ARUTYUNYAN, SEVAKFACILITY TYPE:
740
ADDRESS:17201 LAHEY STTELEPHONE:
(818) 535-9693
CITY:GRANADA HILLSSTATE: CAZIP CODE:
91344
CAPACITY:6CENSUS: 4DATE:
05/19/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:47 PM
MET WITH:Sevak Arutyunyan - AdministratorTIME COMPLETED:
03:45 PM
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Licensing Program Analyst (LPA) Gary Tan for a One (1) Year Required - Infection Control visit for this facility. LPA initially met with staff Naira Alikhanyan and called administrator who Sevak arrived around 30 minutes later. LPA explained the reason for the visit.

A tour of the physical plant was conducted at 1:11 PM and the following was noted:

There is only one entrance being utilized at the facility, the main door. There are required poster posted at the main door. Screening area is located immediately upon entrance. Sign in sheet, hand sanitizer, gloves and masks are available. LPA was screened upon entry. All staff were observed to be wearing mask upon entrance and during visit.

The facility had submitted and approved Mitigation plan.

Signs to wear a mask and other Covid 19 prevention protocol signs were posted outside the doors. Hand washing, coughing etiquette, physical distancing and other necessary signs were posted in the bathroom and all over the facility. The facility has a designated visitors' area at the backyard. The facility has sufficient stock of PPE in the storage room.

The facility has four (4) bedrooms and two (2) bathrooms currently occupying four (4) residents. One (1) bathroom is designated for the staff. The facility is licensed to care for six (6) non-ambulatory residents, two of them may be bedridden client on Room #4. Hospice Waiver for six (6) residents.

(continued on LIC 809-C)
SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Jose Gary TanTELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:

DATE: 05/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2021
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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: GRANADA GOLDEN YEARS
FACILITY NUMBER: 197609748
VISIT DATE: 05/19/2021
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(continued on LIC 809-C)

Physical environment was checked for cleanliness and condition. Walls, windows, ceilings, floors and floor coverings, and doors were checked, the following was noted:

Living and dining room furniture were also checked. The living room is neat and clean along with the family room. The facility maintains a comfortable temperature at 75°F. The smoke detectors are observed to be operational. There is a fire extinguisher near the dining table and observed to be full and current.

The backyard of the facility has outdoor furniture, with a covered shaded area for clients. There is no body of water at the facility

The garage is attached to the home but has no access from the inside. It is currently being used as used equipment and other supplies storage. It is locked and inaccessible to residents. Laundry area is in the kitchen and the laundry detergents and other cleaning agents were observed to be locked in a kitchen cabinet. Food Service/Kitchen area was sufficiently stocked with two (2) days perishable and has sufficient stock of non-perishable food for (7) days. Frozen foods are wrapped and stored appropriately. Food storage and preparation areas are clean and inaccessible to pests.

The Clients' rooms are adequately furnished with appropriate furniture and lighting system. Clients have sufficient amounts of personal hygiene product which is provided by the licensee.

The bathroom was checked for cleanliness and proper operation. LPA observed the appropriate grab bars for the toilet. The hot water temperature measured at 113.2°F. There is enough clean linen available in stock at the cabinet.



Medications: LPA observed medication in the family/TV room cabinet to be locked and inaccessible to residents. First aid appeared to have met all the requirements for the first aid kit.

Exit interview conducted. Copy of this report issued.
SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Jose Gary TanTELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:

DATE: 05/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2021
LIC809 (FAS) - (06/04)
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