<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609844
Report Date: 09/21/2021
Date Signed: 09/21/2021 11:05:49 AM

COMPREHENSIVE INSPECTION
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. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:PEACH PALACE SENIOR CARE 1 FACILITYFACILITY NUMBER:
197609844
ADMINISTRATOR:KAVUKCHYAN, ARMINEFACILITY TYPE:
740
ADDRESS:6934 PEACH AVENUETELEPHONE:
(818) 854-2325
CITY:VAN NUYSSTATE: CAZIP CODE:
91406
CAPACITY:6CENSUS: 0DATE:
09/21/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:55 AM
MET WITH:Yervand KavukchyanTIME COMPLETED:
11:10 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
At 9:55 a.m., Licensing Program Analyst (LPA) Emily Peraldi arrived at the facility unannounced to conduct a required annual visit. Administrator, Armine Kavukchyan was unavailable for today’s visit. LPA met with staff Yervand Kavukchyan and Administrator authorized staff Yervand Kavukchyan to sign the report.

Peach Palace Senior Care 1 currently has no residents. Administrator explained that the Regional Office was notified back in February that the facility will remain empty until further notice. Administrator said that the facility is not surrendering their license and will remain vacant until the end of the year.

Between 9:56 a.m. – 10:20 a.m., LPA toured the facility with staff. The facility is currently getting remodeled. At 9:56 a.m. LPA observed workers taking out trash and junk out of the facility. Two (2) out of three (3) bedrooms are partially empty with only beds inside. The other bedroom is being used as storage. The rest of the facility is being prepared for remodeling. The remodeling will consistent of painting all the rooms of the facility and new furniture.

No deficiencies were observed at this time. Exit interview conducted. Report issued and a copy of the report was provided via email.
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 593-4493
LICENSING EVALUATOR NAME: Emily PeraldiTELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:

DATE: 09/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2021
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 1