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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609788
Report Date: 12/20/2022
Date Signed: 12/20/2022 02:52:04 PM

Document Has Been Signed on 12/20/2022 02:52 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, GAYANEFACILITY TYPE:
740
ADDRESS:18915 LIEDAN STTELEPHONE:
(818) 917-5104
CITY:NORTHRIDGESTATE: CAZIP CODE:
91324
CAPACITY: 6CENSUS: DATE:
12/20/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:35 PM
MET WITH:Gayane Khachaturova, Administrator TIME COMPLETED:
03:20 PM
NARRATIVE
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Licensing Program Analyst (LPA) Angela Panushkina conducted an unannounced case management visit at this facility to issue deficiency in conjunction with complaint control # 31-AS-20221215161509, wherein during the course of investigation regarding this complaint, LPA observed the following:
  • Upon arrival, LPA checked Licensing Information System (LIS) and observed Staff #1 and Staff #2 were not fingerprinted and or associated with this facility.

Citation issued on LIC809-D and appeal rights discussed.

Exit interview conducted. Copy of this report issued
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Angela Panushkina
LICENSING EVALUATOR SIGNATURE: DATE: 12/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/20/2022
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
Document Has Been Signed on 12/20/2022 02:52 PM - It Cannot Be Edited


Created By: Angela Panushkina On 12/20/2022 at 02:00 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: NORTHRIDGE GARDENS BOARD & CARE, INC.
FACILITY NUMBER: 197609788

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/20/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/21/2022
Section Cited
CCR
87355(e)(2)

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87355 Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified...
This requirement is not met as evidenced by:
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Administrator has agreed to either have the staff get fingerprinted or submit the request for transfer. Administrator will provide an updated LIC500 to reflect new staff.
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Based on record review, the licensee did not comply with the section cited above. S1 and S2 were not associated to the facility which poses an immediate health, safety risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Nichelle Gillyard
LICENSING EVALUATOR NAME:Angela Panushkina
LICENSING EVALUATOR SIGNATURE:
DATE: 12/20/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/20/2022


LIC809 (FAS) - (06/04)
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