197609864-9-23-2022-29-AS-BBAI-CJJPYA-20220923114337

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609864
Report Date: 09/23/2022
Date Signed: 09/23/2022 11:50:46 AM

Document Has Been Signed on 09/23/2022 11:50 AM - 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. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	GRANT SERENITY HOMES OF SF VALLEY, INC		FACILITY NUMBER:	197609864
ADMINISTRATOR:	ADJIAN, MARTIN		FACILITY TYPE:	740
ADDRESS:	6928 PEACH AVE		TELEPHONE:	(818) 425-6797
CITY:	VAN NUYS	STATE: CA	ZIP CODE:	91406
CAPACITY:	6	CENSUS: 6	DATE:	09/23/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Nvard Gevorkian - Licensee		TIME COMPLETED:	12:00 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) Brian Balisi arrived at the facility unannounced to conduct a required annual visit. LPA was greeted and screened by staff. LPA explained the reason for the visit to Licensee Nvard Gevorkian. This annual had a specific emphasis on infection control practices and procedures. At approximately 10am, LPA toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. Fire extinguishers were observed fully charged and last serviced in September. LPA observed the kitchen/dining area to be clean at the time of the visit. Knives are stored in a locked drawer to the right of the stove. Kitchen appliances appeared to be in operable condition. The facility has a sufficient supply of perishable food properly stored. Non-perishable food was observed kept in a locked pantry room inaccessible to residents in care. Laundry room was located next to pantry room and it was observed locked and inaccessible to residents in care. LPA observed resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. Inside temperature was maintained at a comfortable level. Restrooms were observed to be relatively clean, sanitary and in operating condition with grab bars and non-skid mats. Hot water measured between 105 - 120 degrees Fahrenheit. LPA observed common area to be relatively clean and properly furnished. There is a fireplace that is adequately screened. LPA also observed puzzles and different activities for the residents. At approximately 10:30am, LPA observed (2) residents watching television in the living room. There is an office area to the right of the kitchen. Medications were observed stored in a locked cabinet and locked fridge outside of room 3 inaccessible to residents in care.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian Balisi	TELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:	DATE: 09/23/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2022

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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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. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: GRANT SERENITY HOMES OF SF VALLEY, INC	FACILITY NUMBER: 197609864
	VISIT DATE: 09/23/2022

NARRATIVE

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Continued from LIC 809.

LPA observed the back patio, with a shaded area and appropriate outdoor furniture for resident use. LPA observed a detached garage. Disinfectants, cleaning solutions, incontinent supplies are stored inaccessible to residents in this area. LPA also observed 7 day emergency food supply kept in the garage as well. Storage room in the rear of the garage was observed to store a sufficient amount of PPE. Behind the garage LPA observed (3) buildings for storage. The building closest to the detached garage was observed to store art pieces. The other (2) storage buildings at the rear of the facility stored decorations, medical equipment, and other supplies for facility use. Next to the detached garage LPA observed an empty pool that was gated and inaccessible to residents in care. The outdoor area behind the detached garage is inaccessible to residents in care at this time. There is a gate on the side of the facility designated for an emergency exit. Passageways were free and clear from obstruction. LPA observed shaded seating area with appropriate outdoor furniture in the front of the facility as well.

INFECTION CONTROL: The LPA spoke with Nvard regarding the facility’s infection control practices. Upon entry, the facility has a central entry point for symptom screening, temperature checks, and sanitation station. The facility has an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate each resident to their private room if the facility has a confirmed case of COVID-19. COVID-19 testing will be conducted twice a week if there are any COVID-19 concerns. The facility’s policies and procedures as it pertains to infection control are adequate at this time.

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: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian Balisi	TELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:	DATE: 09/23/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2022

LIC809 (FAS) - (06/04)

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