197609842-11-4-2023-31-AS-MCAA-CX9UMB-20231104154204

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609842
Report Date: 11/04/2023
Date Signed: 11/04/2023 03:42:35 PM

Document Has Been Signed on 11/04/2023 03:42 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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	SAINT NICK ASSISTED LIVING		FACILITY NUMBER:	197609842
ADMINISTRATOR:	YEGEYAN, MARY		FACILITY TYPE:	740
ADDRESS:	17177 SAN JOSE STREET		TELEPHONE:	(818) 488-9109
CITY:	GRANADA HILLS	STATE: CA	ZIP CODE:	91344
CAPACITY:	6	CENSUS:	DATE:	11/04/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:40 AM
MET WITH:	Nazar "Nick" Yegeyan		TIME COMPLETED:	12:30 PM

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 the administrator, 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 is brand new. It is located in the kitchen. 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 with sufficient lighting. 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 111 degrees Fahrenheit. No cleaning supplies were observed. Common Areas: These included the living room and dining area. The common areas were properly furnished. The dining room table is large enough to seat up to six residents. Floors were cleaned, maintained and clear of obstruction. The auditory alarms on all exit doors were on and functional at the time of the visit. All exits were clear of obstruction.

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Michael Cava	TELEPHONE: (818) 389-7921
LICENSING EVALUATOR SIGNATURE:	DATE: 11/04/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2023

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: 11/04/2023

NARRATIVE

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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 is located in the hallway by the staff bathroom. No detergents or cleaning supplies observed. The staff office/work station is located at the back end of the home. Resident and staff files are maintained locked there. The garage is utilized as an 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 were review for proper 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: 11/04/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2023

LIC809 (FAS) - (06/04)

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