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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
197609788
Report Date:
05/22/2022
Date Signed:
05/22/2022 01:29:57 PM
Document Has Been Signed on
05/22/2022 01:29 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:
NORTHRIDGE GARDENS BOARD & CARE, INC.
FACILITY NUMBER:
197609788
ADMINISTRATOR:
KHACHATUROVA, GAYANE
FACILITY TYPE:
740
ADDRESS:
18915 LIEDAN ST
TELEPHONE:
(818) 917-5104
CITY:
NORTHRIDGE
STATE:
CA
ZIP CODE:
91324
CAPACITY:
6
CENSUS:
4
DATE:
05/22/2022
TYPE OF VISIT:
Case Management - Other
UNANNOUNCED
TIME BEGAN:
12:00 PM
MET WITH:
Gayane Khachaturova
TIME COMPLETED:
01:40 PM
NARRATIVE
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An unannounced Collateral Visit in conjunction with a Subsequent Complaint visit was conducted on this day by Licensing Program Analyst (LPA )Yelena Avetisyan. The purpose of this visit is to Deliver complaint investigation findings for a complaint filed against Lake Balboa Board & Care (Complaint Control # 31-AS-20200211152628) Facility # 197609114 which is no longer operating. The licensee/Administrator for this facility Gayane Khachaturova was identified as the Operator for Lake Balboa Board & Care.
Upon arrival LPA met with Staff Anna Pirumyan and Angin Tovmasyan. Ms. Pirumyan contacted Ms. Khachaturova who arrived at the facility approximately 12:20 pm.
While waiting at the facility the LPA conducted a brief tour of the facility with staff Pirumyan. Upon arrival to the home LPA observed a Permit issued for an ADU to be built. LPA informed Ms. Khachaturova that she will need to submit written plan to the department/LPA regarding their plans.
Exit interview conducted and copy of report emailed to the
GAYANA79@HOTMAIL.COM
SUPERVISORS NAME
:
Eva Miller
LICENSING EVALUATOR NAME
:
Yelena Avetisyan
LICENSING EVALUATOR SIGNATURE
:
DATE:
05/22/2022
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
05/22/2022
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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