197609842-11-16-2024-31-AS-MCAA-DB3VHJ-20241116152712

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609842
Report Date: 11/16/2024
Date Signed: 11/16/2024 03:27:56 PM

Document Has Been Signed on 11/16/2024 03:27 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:	SAINT NICK ASSISTED LIVING		FACILITY NUMBER:	197609842
ADMINISTRATOR/ DIRECTOR:	YEGEYAN, MARY		FACILITY TYPE:	740
ADDRESS:	17177 SAN JOSE STREET		TELEPHONE:	(818) 488-9109
CITY:	GRANADA HILLS	STATE: CA	ZIP CODE:	91344
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS:	DATE:	11/16/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:34 AM
MET WITH:	Mary Yegeyan, Mary Yegeyan		TIME VISIT/ INSPECTION COMPLETED:	11:23 AM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Michael Cava conducted an Annual Required visit and inspection of the facility. LPA met with administrators, Mary Yegeyan and Nazar "Nick" Yegeyan and explained the reason for the visit. At approximately 8:45am, with the assistance of the administrator, LPA took a tour of the physical plant. The facility is a one story building. No swimming pool or bodies of water on property. The smoke alarms are hardwired. There are carbon monoxide works dual with the smoke alarms. The fire extinguisher new. It is located in the kitchen. Purchase date is 04/11/24 Kitchen: The kitchen appliances and fixtures were functional. LPA found a sufficient amount of perishable and non-perishable food at the facility; properly stored. Additional food, perishable and non-perishable food items are also stored in the garage. Knives were stored in a locked box inside a kitchen drawer. Bedrooms: There are three (3) bedrooms designated for residents' use. The three bedrooms are shared. Bedrooms were properly furnished with appropriate beddings and linens and closet space. There is sufficient lighting in all rooms that were inspected. Bathrooms: There are two and one half (2 1/2) bathrooms. Bathrooms were properly supplied and had functional fixtures. Hot water temperature was measured at 113 degrees Fahrenheit. No cleaning supplies were observed. Common Areas: These included the living room and dining area. The living room had two couches, recliner and table. There is extra seating around with additional side tables. The dining room has a table large enough to seat up to six (6) residents. Furniture were in good repair. Floors were mopped and clean.

Eva Miller	TELEPHONE: (818) 596-4373
Michael Cava	TELEPHONE: (818) 389-7921
	DATE: 11/16/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2024

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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: SAINT NICK ASSISTED LIVING	FACILITY NUMBER: 197609842
	VISIT DATE: 11/16/2024

NARRATIVE

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Internal temperature was set at 70 degrees. The auditory alarms on all exit doors were on and functional at the time of the visit. All exits were clear of obstruction.

Surrounding Grounds: Entry/exits were free of obstruction. There was furniture in the backyard appropriate for outdoor use. The front and backyard has sufficient space to hold outdoor activities.

Laundry area: The laundry area is located in the hallway by the staff bathroom. No detergents or cleaning supplies observed.

Staff office/work station: The staff office/work station is located at the back end of the home. There is a desk and additional seating. Resident and staff files are maintained locked there. Staff office/work statin leads to the backyard.

Garage: Garage is attached to the home. Garage is locked and inaccessible to residents. Garage is used for extra storage space.

Resident Files: LPA conducted a file review of resident records to insure compliance of licensing forms.

Staff Files: LPA also conducted a file review of staff records to insure forms and training are up to date and compliance with licensing forms.

Medications: Medication and Medication Records are stored in a locked cabinet at the staff office/work station. Medications and medication records were reviewed for proper storage and documentation.

Pursuant to Title 22 Division 6 of the CA Code of Regulations, there were no deficiencies observed during the visit. Exit Interview Conducted and a Copy of the Report Issued.

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Michael Cava	TELEPHONE: (818) 389-7921
LICENSING EVALUATOR SIGNATURE:	DATE: 11/16/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2024

LIC809 (FAS) - (06/04)

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