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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609992
Report Date: 12/20/2023
Date Signed: 12/20/2023 02:52:02 PM

Document Has Been Signed on 12/20/2023 02:52 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:GEVART A.R.F. INCFACILITY NUMBER:
197609992
ADMINISTRATOR:GHAZARYAN, YERANUHIFACILITY TYPE:
735
ADDRESS:8651 ROSLYNDALE AVETELEPHONE:
(323) 219-5454
CITY:ARLETASTATE: CAZIP CODE:
91331
CAPACITY: 4CENSUS: 3DATE:
12/20/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:50 AM
MET WITH:Doreen Mwolobi, Derrick SsenkonyoTIME COMPLETED:
02:45 PM
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Licensing Program Analyst (LPA) Michael Cava conducted an Annual Required visit and inspection of the facility. LPA met with staff, Doreen Mwolobi and Derrick Ssenkonyo, and explained the reason for the visit.

At 12:00pm, with the assistance of staff, LPA took a tour of the physical plant. The facility is a Level 3 home. Required postings were observed in the living room area. Dual Smoke alarms and carbon monoxide are hardwired and interconnected. They were tested and operable during the day's visit. The fire extinguisher is located in the kitchen. It was purchased on 10/25/23.

Kitchen: The kitchen appliances and fixtures were functional. LPA found a sufficient amount of perishable and non-perishable food at the facility; properly stored. Knives and cleaning supplies were stored inaccessible to the residents. Laundry area is accessible through kitchen. It was observed to be clean and appliances in good repair. Laundry detergents and cleaners locked in cabinet above dryer.

Bedrooms: There are five (5) bedrooms, of which, four (4) are designated for residents' use. One bedroom is designated for staff. The bedrooms designated for residents were were properly furnished with appropriate beddings and linens with sufficient lighting.

Bathrooms: There are two (2) bathrooms designated for residents' use. Both bathrooms were properly supplied and had functional fixtures. Hot water temperature was measured at 108 degrees Fahrenheit. There are no cleaning supplies stored in the bathroom.

Common Areas: These included the living room and dining area. The common areas were properly furnished. Floors were clean and the furniture were in good repair. The dining room table is large enough to seat six residents.
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Michael Cava
LICENSING EVALUATOR SIGNATURE: DATE: 12/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/20/2023
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 2
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: GEVART A.R.F. INC
FACILITY NUMBER: 197609992
VISIT DATE: 12/20/2023
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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.

Garage: The garage is converted to office space. It is also storage for excess food.

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 closet by the living room. Medications 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.
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Michael Cava
LICENSING EVALUATOR SIGNATURE:

DATE: 12/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2023
LIC809 (FAS) - (06/04)
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