197609748-11-3-2023-31-AS-MCAA-CX8SRB-20231103140606

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609748
Report Date: 11/03/2023
Date Signed: 11/03/2023 02:06:45 PM

Document Has Been Signed on 11/03/2023 02:06 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:	GRANADA GOLDEN YEARS		FACILITY NUMBER:	197609748
ADMINISTRATOR:	ARUTYUNYAN, SEVAK		FACILITY TYPE:	740
ADDRESS:	17201 LAHEY ST		TELEPHONE:	(818) 535-9693
CITY:	GRANADA HILLS	STATE: CA	ZIP CODE:	91344
CAPACITY:	6	CENSUS: 3	DATE:	11/03/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:18 AM
MET WITH:	Mariam Balasanyan		TIME COMPLETED:	02:15 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Michael Cava conducted an Annual Required visit and inspection of the facility. LPA met with the administrator, Mariam Balasanyan and explained the reason for the visit. At approximately 11:18am, with the assistance of the administrator, LPA took a tour of the physical plant. Required postings were observed in the entry area. The smoke alarms and carbon monoxide detector is dual and are hardwired. There is a fully charged fire extinguisher is located near the dining room. Kitchen: The kitchen appliances and fixtures were functional. LPA found a sufficient amount of perishable and non-perishable food at the facility; properly stored. Knives were stored in a locked drawer in the kitchen. Bedrooms: There are four (4) bedrooms designated for residents' use. The bedrooms, in use by residents were properly furnished with appropriate beddings and linens with sufficient lighting. Bathrooms: There are two (2) bathrooms. One bathroom designated for residents, and one designated for staff. The bathrooms used by residents were properly supplied and had functional fixtures. Hot water temperature was measured at 105 degrees Fahrenheit. There were no cleaning supplies observed in the bathrooms. Common Areas: These included the living room, family room and dining area. The common areas were properly furnished. The auditory alarms on all exit doors were on and functional at the time of the visit. Medications and medication records are kept locked in a closet located at the living room. Staff and resident records are also maintained there.

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Michael Cava	TELEPHONE: (818) 389-7921
LICENSING EVALUATOR SIGNATURE:	DATE: 11/03/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2023

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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: GRANADA GOLDEN YEARS	FACILITY NUMBER: 197609748
	VISIT DATE: 11/03/2023

NARRATIVE

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Surrounding Grounds: Entry/exits were free of obstruction. There was furniture appropriate for outdoor
use. The outdoor area was free of hazards. The laundry area is located by the kitchen. There is a locked cabinet by the laundry area where detergents and cleaning supplies are kept.

Resident Files: LPA conducted a file review of resident records to insure compliance of licensing forms.

Staff Files: LPA also conducted a file review of staff records to insure forms and training are up to date and compliance with licensing forms.

Medications: Medication and Medication Records were review for proper documentation.

Pursuant to Title 22 Division 6 of the CA Code of Regulations, there were no deficiencies observed during the visit. Exit Interview Conducted and a Copy of the Report Issued.

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Michael Cava	TELEPHONE: (818) 389-7921
LICENSING EVALUATOR SIGNATURE:	DATE: 11/03/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2023

LIC809 (FAS) - (06/04)

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