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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610017
Report Date: 01/18/2022
Date Signed: 01/18/2022 12:25:59 PM

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:SHERWOOD FOREST SENIOR LIVINGFACILITY NUMBER:
197610017
ADMINISTRATOR:MKRTCHYAN, ANIFACILITY TYPE:
740
ADDRESS:8635 AMESTOY AVENUETELEPHONE:
(818) 322-2222
CITY:SHERWOOD FORESTSTATE: CAZIP CODE:
91325
CAPACITY:6CENSUS: 3DATE:
01/18/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Gohar AkashyanTIME COMPLETED:
12:45 PM
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Licensing Program Analyst (LPA), Patrick Shanahan, Arrived at the facility and was greeted by facility staff. LPA had his temperature taken at the front door and was not allowed entry until all covid measures were completed.

LPA conducted an Infection Control Annual Visit. The home has 5 bedrooms and 2 bathrooms. The facility appeared clean and sanitary. All smoke alarms and carbon monoxide detectors were functioning properly and the fire extinguisher appeared functional. There are no pools or other bodies of water present at the home.

The facility is following their approved mitigation plan and no deficiencies were observed.

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: 01/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/18/2022
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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