197610123-3-23-2022-31-AS-APAA-CCSSW9-20220323141357

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610123
Report Date: 03/23/2022
Date Signed: 03/23/2022 02:15:01 PM

Document Has Been Signed on 03/23/2022 02:15 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:	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: 6	DATE:	03/23/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:45 AM
MET WITH:	Nazar Yegeyan, Administrator		TIME COMPLETED:	02:35 PM

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At 11:45am Licensing Program Analyst (LPA), Angela Panushkina, conducted an unannounced annual inspection at the facility mentioned above. LPA was greeted by staff, Aida Hambardzumyan, who granted access to the facility. Administrator arrived at 12:00pm and LPA explained the reason for the visit.

LPA conducted a physical tour with the Administrator and observed the following:

Infection control: LPA reviewed the facility mitigation plan (approved on 07/27/2021) to make sure licensee was following current infection control recommendations. Upon arrival, LPA was screened and asked to sign-in the visitors’ log. In addition, LPA was asked all infection control questions. Proper signage was observed inside along the hallway and in the restrooms. Hand sanitizer was also observed. Administrator stated they have sufficient PPE supplies for residents and staff. LPA observed all trash can throughout the facility have fitted lids.

Kitchen: At approximately, 12:05pm LPA toured the kitchen area and observed enough supplies of staple non-perishable for minimum 1 week and perishable for 2 days at the facility. All knives and sharps are observed to be locked in a kitchen cabinet and inaccessible to residents.

Medications: At approximately, 12:10pm LPA observed medications are centrally stored and locked in the cabinet, by the dining area and inaccessible to residents in care.

Bedrooms: There are four (4) bedrooms designated for residents use and have sufficient lighting. All bedrooms are properly furnished, clean and have appropriate bedding and linens. Auditory alarms were tested and observed to be operational

Continue on LIC809-C

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Angela Panushkina	TELEPHONE: 747-230-3364
LICENSING EVALUATOR SIGNATURE:	DATE: 03/23/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/23/2022

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., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: CONCORDIA ASSISTED LIVING	FACILITY NUMBER: 197610123
	VISIT DATE: 03/23/2022

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Bathrooms: At 12:25pm LPA observed all bathrooms are clean and in good repair. Properly supplied with toilet papers, soap and paper towels. The hot water temperature measured at 117.0°F. LPA observed appropriate grab bar and showers had non-skid mats. LPA observed appropriate hand washing signs posted in each bathroom.

Common Areas: The facility maintains a comfortable temperature at 77°F. The living room and dining area appeared clean and were properly furnished. Laundry area is located near the kitchen. Facility has two (2) fire extinguishers (one in the kitchen and one by the laundry area) and both were last purchased on 03/10/22.

Outside areas: At approximately, 12:45pm LPA toured the outside area of the facility. LPA observed appropriate outdoor furniture, with a covered shaded area for residents. LPA discussed the importance of maintaining the care and supervision to meet the needs of residents. There are no bodies of water.

Smoke detectors/carbon monoxide. Dual smoke and carbon monoxide detectors were located throughout the facility, and at 1:00pm they were tested and observed to be operational.

Administrative: Certificate of Liability Insurance, and LIC.500 will be emailed to LPA.

No citations issued during this visit. Exit interview conducted. Copy of report emailed to Licensee.

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Angela Panushkina	TELEPHONE: 747-230-3364
LICENSING EVALUATOR SIGNATURE:	DATE: 03/23/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/23/2022

LIC809 (FAS) - (06/04)

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