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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610042
Report Date: 12/19/2023
Date Signed: 12/19/2023 03:22:35 PM

Document Has Been Signed on 12/19/2023 03:22 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:DAVID'S ADULT RESIDENTIAL FACILITY INC.FACILITY NUMBER:
197610042
ADMINISTRATOR:MANAVCHYAN, HERMINEFACILITY TYPE:
735
ADDRESS:16705 KINZIE ST.TELEPHONE:
(323) 326-6364
CITY:NORTHRIDGESTATE: CAZIP CODE:
91343
CAPACITY: 4CENSUS: 4DATE:
12/19/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Hermine Manavchyan, AdministratorTIME COMPLETED:
03:50 PM
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At 2:00pm, Licensing Program Analyst (LPA) Angela Panushkina arrived at the facility to conduct an unannounced annual inspection. Upon arrival, LPA was greeted by the Administrator, who granted access to the facility. LPA observed hand sanitizer and covid-19 signage posted throughout the facility’s main hallway. LPA conducted an entrance interview, and the purpose of the visit was explained.

LPA initiated a physical plant tour. Facility is an Adult Residential Facility, vendored by North Los Angeles Regional Center. Facility is licensed for 4 ambulatory clients. LPA was able to tour the facility and did not observe any immediate health and safety concerns. Fully charged fire extinguisher was observed in the kitchen. LPA also observed enough supplies of staple non-perishable for minimum 1 week and perishable for 2 days at the facility. All knives and sharps observed to be locked in a hallway cabinet by the kitchen. Medication is centrally stored and locked in a hallway closet by the living room area. Facility has four (4) bedrooms, two (2) bathrooms. Bedrooms are appropriately furnished and have appropriate lighting. Bathrooms have soap, paper towels and hand washing signs. Extra towels and linens were readily available. Sufficient PPE supplies were observed in a hallway closet. Dual smoke detectors and carbon monoxide were located throughout the facility, and at 2:50pm they were tested and observed to be operational. LPA toured the outside area of the facility. LPA observed appropriate outdoor furniture, with a covered shaded area for clients. LPA discussed the importance of maintaining the care and supervision to meet the needs of clients.

Between 3:00pm to 3:30pm, LPA reviewed records of four (4) clients and two (2) staff. Client and staff records appeared to be complete and updated. LPA collected Certificate of Liability Insurance, and LIC500.

No deficiency cited during todays visit.

Exit interview conducted and copy of this report signed and delivered.

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Angela Panushkina
LICENSING EVALUATOR SIGNATURE: DATE: 12/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/19/2023
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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