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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609788
Report Date: 01/06/2023
Date Signed: 01/06/2023 09:30:00 AM

Document Has Been Signed on 01/06/2023 09:30 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:NORTHRIDGE GARDENS BOARD & CARE, INC.FACILITY NUMBER:
197609788
ADMINISTRATOR:KHACHATUROVA, GAYANEFACILITY TYPE:
740
ADDRESS:18915 LIEDAN STTELEPHONE:
(818) 917-5104
CITY:NORTHRIDGESTATE: CAZIP CODE:
91324
CAPACITY: 6CENSUS: 4DATE:
01/06/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Gayane Khachaturova, Administrator.TIME COMPLETED:
09:30 AM
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At 9:00am, LPA conducted an unannounced Case Management Visit to this facility. LPA met with the Administrator and explained the reason for the visit. Entrance interview conducted.

After review of complaint #31-AS-20221215161509, a deficiency was issued on 12/20/2022. In addition, on 05/26/22 the facility was issued another deficiency for the same violation and it had been determined that a civil penalty should be assessed.

During todays visit a Civil Penalty was issued.

Exit interview conducted, appeal rights explained and copy of this report provided to the Administrator.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Angela Panushkina
LICENSING EVALUATOR SIGNATURE: DATE: 01/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/06/2023
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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