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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609789
Report Date: 07/25/2024
Date Signed: 07/25/2024 06:54:26 PM

Document Has Been Signed on 07/25/2024 06:54 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.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:LAURELGROVE MANOR 2FACILITY NUMBER:
197609789
ADMINISTRATOR/
DIRECTOR:		AVETIS VARDANYANFACILITY TYPE:
735
ADDRESS:13557 RANGOON STTELEPHONE:
(747) 272-3093
CITY:ARLETASTATE: CAZIP CODE:
91331
CAPACITY: 4CENSUS: 4DATE:
07/25/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
04:02 PM
MET WITH:Alvard Yervandyan - AdministratorTIME VISIT/
INSPECTION COMPLETED:
07:00 PM
NARRATIVE
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A Required One (1) year visit was conducted today by Licensing Program Analyst (LPA) Gary Tan. LPA met with administrator Alvard Yervandyan. Purpose of visit was stated. This is a North Los Angeles Regional vendored facility Level II.

A tour of the physical plant was conducted at 4:15 PM and the following was noted:

The main door is the only entrance being utilized. Screening area is located immediately after entry. Sign in she et, hand sanitizer, gloves and masks are available. Covid 19 prevention protocol signs were posted inside the facility: Hand washing, coughing etiquette, physical distancing, and other necessary signs were posted in the bathroom and all over the facility. All trash cans were observed to be with cover. The facility had submitted and approved Mitigation plan.

The facility has a designated visitors' area at the backyard. The facility has sufficient stock of PPE in the storage room.

This is a single storey home with four (4) private client bedrooms, additional one (1) staff bedroom and two (2) bathrooms. One (1) bedroom and one (1) bathroom is designated for staff use. There is no body water in the facility.

Bedrooms were toured and observed to be clean and properly furnished. Linen storage was also checked and observed to have ample supply of clean linen and towels.
Bathrooms were observed to be clean and sanitary with necessary supplies. Hot water temperature measured at 118.2°F and within the required range.

(continued to LIC 809-C)
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE: DATE: 07/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/25/2024
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
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: LAURELGROVE MANOR 2
FACILITY NUMBER: 197609789
VISIT DATE: 07/25/2024
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Physical plant was checked for cleanliness and condition. Facility was in good repair and observed to be clean and free of clutter during today's visit.
Living and dining room furniture were also checked for functionality (wear and tear). Furniture was observed to be in good condition.
Kitchen area was observed to be clean and sanitary. All the toxins, cleaning solutions and disinfectants are locked in the cabinet in the laundry area.
Food. The facility is observed to have sufficient food supply for the clients both perishable and non-perishable.
Temperature of facility wall thermostat is observed to be within the required range.
Fire extinguisher There is a fire extinguisher located in the kitchen. Extinguisher was observed to be full and last inspected on 10/20/23. Smoke alarms are hardwired and interconnected. Carbon monoxide and smoke alarms were tested and observed to be operable.

The Garage is now separated to the house divided by a 6 foot fence and currently being constructed to become an Additional Dwelling Unit (ADU). The garage and the shed are now inaccessible from the house. Laundry area is located in the staff bathroom. Laundry detergents and other cleaning agents and toxins are kept locked in the cabinet in the laundry area. Knives and sharps are kept in the medication cabinet.

Medication was observed to be inaccessible and stored in a secured medication cabinet located in the bedroom hallway. There is a complete First Aid kit that is easily accessible.


Client records were also reviewed. Clients’ record appeared to be complete and current.
Staff records were also reviewed. Staff present has criminal record clearances and associated to this facility. Current training and first aid observed for staff on duty. Administrator's certificate observed to be current.

Disaster drill was last conducted on 06/30/24. Required posting observed in facility (complaint hot line poster, personal rights, etc).

There was no immediate health and safety hazard observed during the day of inspection. Exit interview conducted and a copy of this report was given.

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE:

DATE: 07/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/25/2024
LIC809 (FAS) - (06/04)
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