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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609789
Report Date: 11/21/2023
Date Signed: 11/21/2023 04:42:47 PM

Document Has Been Signed on 11/21/2023 04:42 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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:LAURELGROVE MANOR 2FACILITY NUMBER:
197609789
ADMINISTRATOR:AVETIS VARDANYANFACILITY TYPE:
735
ADDRESS:13557 RANGOON STTELEPHONE:
(747) 272-3093
CITY:ARLETASTATE: CAZIP CODE:
91331
CAPACITY: 4CENSUS: 3DATE:
11/21/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:AVETIS VARDANYANTIME COMPLETED:
05:00 PM
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Licensing Program Analyst (LPA) Christopher Alemoh conducted an Annual Required visit and inspection of the facility. LPA met with Administrator, Alvard Yervandyan and staff Inga Corneacova and explained the reason for the visit. Staff performed temperature check before granted entry.

At 02:45pm, with the assistance of staff, LPA took a tour of the physical plant. Required postings were observed in the entry area. The smoke alarms are hardwired and interconnected. There are carbon monoxide detectors that functions properly. The fire extinguisher is located in the kitchen. The charge date is 10/20/2023. Last fire drill was 09/03/2023.

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. Properly labeled medications were locked in one of the closets in the hallway cabinets. LPA measured Kitchen Temp at 116 degrees Fahrenheit.

Bedrooms: There were five (4) bedrooms designated for residents' use. Three of the bedrooms in use by residents were properly furnished with appropriate beddings and linens with sufficient lighting. One bedroom is vacant and empty. One room has been designated as a staff room.

Bathrooms: There are two (2) bathrooms designated for residents' use. Both bathrooms were properly supplied and had functional fixtures. Hot water temperature was measured at 114 degrees Fahrenheit. Cleaning supplies are being stored in the hallway bathroom.

Common Areas: These included the living room and dining area. The common areas were properly furnished.
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Christopher Alemoh
LICENSING EVALUATOR SIGNATURE: DATE: 11/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/21/2023
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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: LAURELGROVE MANOR 2
FACILITY NUMBER: 197609789
VISIT DATE: 11/21/2023
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Cont from Lic 809

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 and detergents are located by the kitchen.

At 3:30pm LPA conducted a file review of resident records to ensure compliance of licensing forms.

At 04:15 LPA also conducted a file review of staff records to ensure forms and training are up to date and compliance with licensing forms.

Medications: Medication and Medication Records were review for proper documentation.
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Christopher Alemoh
LICENSING EVALUATOR SIGNATURE:

DATE: 11/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2023
LIC809 (FAS) - (06/04)
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