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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609862
Report Date: 08/15/2022
Date Signed: 08/15/2022 01:07:50 PM


Document Has Been Signed on 08/15/2022 01:07 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:EMERALD ESTATE SENIOR CARE, INCFACILITY NUMBER:
197609862
ADMINISTRATOR:LYSENKO, OLENAFACILITY TYPE:
740
ADDRESS:10401 ENCINO AVETELEPHONE:
(747) 300-2232
CITY:GRANADA HILLSSTATE: CAZIP CODE:
91344
CAPACITY:6CENSUS: 6DATE:
08/15/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Hovhannes Papazyan - StaffTIME COMPLETED:
01:20 PM
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Licensing Program Analyst (LPA), Patrick Shanahan, arrived at the home and was greeted by facility staff. The LPA had his temperature taken and all covid -19 questions asked before being allowed entry. The reason for the visit was in order to conduct an infection control annual.

LPA was able to tour the home and observed that there were 6 residents.

The home has 5 bedrooms and two bathrooms. There were 4 single rooms and one shared. The smoke alarms and carbon monoxide detectors were tested and functioned properly. The fire extinguisher was observed in the kitchen and appeared functional.

The facility is currently following their infection control plan and no deficiencies were observed during the visit. Exit interview conducted and report issued.
SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Patrick ShanahanTELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:
DATE: 08/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/15/2022
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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