197610123-1-11-2021-31-AS-JGTN-BX6L2V-20210111072255

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610123
Report Date: 01/08/2021
Date Signed: 01/11/2021 07:23:03 AM

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:	CONCORDIA ASSISTED LIVING		FACILITY NUMBER:	197610123
ADMINISTRATOR:	YEGEYAN, NAZAR		FACILITY TYPE:	740
ADDRESS:	16704 BLACKHAWK STREET		TELEPHONE:	(818) 403-1803
CITY:	GRANADA HILLS	STATE: CA	ZIP CODE:	91344
CAPACITY:	6	CENSUS: 0	DATE:	01/08/2021
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	08:10 AM
MET WITH:	Nazar Yegeyan - Administrator		TIME COMPLETED:	11:00 AM

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) Gary Tan conducted an announced virtual Pre Licensing tele visit to this facility and met with applicants Nazar and Mary Yegeyan. The applicant is "Concordia Assisted Living". Fire Clearance dated 12/02/2020 was received for six (6) non-ambulatory residents, all of which may be bedridden. Purpose of today’s visit is to inspect the facility to ensure that the facility is in compliance with the rules and regulations of California Code of Regulations, Title 22, Division 6. The facility is a two (2) storey building, the second floor has three (3) bedrooms and designated for staff use only and will not be accessible for residents. Today's site visit consisted of LPA touring the physical plant inside and outside and observed the following: The facility dual smoke/carbon monoxide alarm system is hard wired and interconnected. The fire extinguishers are located in the kitchen and bedroom hall way and were observed to be fully charged and were bought on 12/1/2020. Dual Smoke and Carbon Monoxide detectors were observed all over the facility, tested and observed to be operational, the facility is equipped with fire sprinklers. Hot water was tested in the common bathrooms and measured at an average of 116.6°F. There is a functioning telephone on the premises. An emergency exit plan/sketch is posted on the hallway wall with other posting requirements. There are four (4) resident bedrooms, two (2) private and two (2) shared room. Resident bedrooms were observed to be appropriately furnished. The common areas (living room, kitchen and dining areas) were appropriately furnished and lighting was adequate. The living room has a television and comfortable furniture. Resident and staff records will be stored in a locked filing cabinet in the kitchen area. Medications will also be stored in the separate locked filing cabinet located near the kitchen. The first aid kit is readily available. There are four (4) bathrooms in the facility. One (1) bathroom is designated for staff use only and the common bathroom has non-skid mat and appropriate grab bars installed. (continued on LIC 809-C)

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Jose Gary Tan	TELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:	DATE: 01/08/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/08/2021

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., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: CONCORDIA ASSISTED LIVING	FACILITY NUMBER: 197610123
	VISIT DATE: 01/08/2021

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(continued from LIC 809)

The kitchen knives are stored in a locked toolbox inside a drawer in the kitchen. Kitchen cleaning supplies are stored in a locked cabinet under the kitchen sink. Laundry detergents, cleaning supplies and other toxins are stored in the locked cabinet. The laundry area is located in the bedroom hallway. The necessary precautions have been made to the facility to safely house dementia residents such as auditory alarms on all doors and locked areas for centrally stored medications. Facility appears to be clean and in good repair. Appliances in the kitchen appeared to be functional.

There is a sitting area in the backyard for residents to conduct outdoor activities. The backyard is fenced. The garage is detached and about 20 feet away from the facility and was observed to be locked. There is no body of water in the facility.

The request for Component III to be waived at this facility has been granted by LPM Nichelle Gillyard as this Licensee has recently opened a new facility just a year ago.

Facility is in compliance with Title 22 Regulations at this time. This report will be forwarded to the Centralized Application Bureau (CAB). You will be notified by the CAB Analyst when your license has been approved.

A telephonic exit interview was conducted with Licensee Representative Nazar Yegeyan and a hard copy was provided via email for signature.

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Jose Gary Tan	TELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:	DATE: 01/08/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/08/2021

LIC809 (FAS) - (06/04)

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