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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609790
Report Date: 05/14/2021
Date Signed: 05/14/2021 03:59:25 PM

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:COZY ELDERLY CARE INCFACILITY NUMBER:
197609790
ADMINISTRATOR:ADZEMIAN, VARDANFACILITY TYPE:
740
ADDRESS:10108 COZYCROFT AVETELEPHONE:
(323) 348-8522
CITY:CHATSWORTHSTATE: CAZIP CODE:
91311
CAPACITY:6CENSUS: 0DATE:
05/14/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:38 PM
MET WITH:Vardan Adezemian, LicenseeTIME COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) Rosaura Valenzuela conducted an unannounced case management visit to the facility to ensure that there are no residents in care. LPA met with Vardan Adezemian, Licensee. The purpose of the visit was discussed with the licensee.

At 2:38pm, LPA Valenzuela began a physical plant tour of the facility. LPA inspected the five (5) rooms were residents in care resided. All five (5) rooms were vacant. There were no residents in any of the rooms. LPA looked inside the closets and checked all drawers and saw no personal belongings or clothes inside. LPA observed the kitchen and saw no food.

Exit interview conducted. A hard copy of the report was sent via email to the licensee for signature.
SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Rosaura ValenzuelaTELEPHONE: (818) 421-5360
LICENSING EVALUATOR SIGNATURE:

DATE: 05/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/14/2021
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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