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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610123
Report Date: 07/22/2023
Date Signed: 07/22/2023 02:12:38 PM


Document Has Been Signed on 07/22/2023 02:12 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 LIVINGFACILITY NUMBER:
197610123
ADMINISTRATOR:YEGEYAN, NAZARFACILITY TYPE:
740
ADDRESS:16704 BLACKHAWK STREETTELEPHONE:
(818) 403-1803
CITY:GRANADA HILLSSTATE: CAZIP CODE:
91344
CAPACITY:6CENSUS: 6DATE:
07/22/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Emma Arutiunian, Aida Andriasyan, Gagik MkrtchyanTIME COMPLETED:
02:30 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, Emma Arutiunian, Aida Andriasyan, and Gagik Mkrtchyan. They were advised of the purpose for the visit.

At approximately 9:45am, with the assistance of staff, LPA took a tour of the physical plant. The facility is a two (2) story building, the second floor has three (3) bedrooms and designated for staff use only and will not be accessible for residents. Required postings were observed in the entry area. The smoke alarms and the carbon monoxide detectors are dual and installed throughout the facility. The facility has two fully charged fire extinguishers. One fire extinguisher is located in the hallway, and the other near the kitchen.

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 were stored in a locked drawer in the kitchen. Properly labeled medications were locked in one of the kitchen cabinets.

Bedrooms: There were four (4) bedrooms designated for residents' use. All the bedrooms were properly furnished with appropriate beddings and linens with sufficient lighting.

Bathrooms: 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. Hot water temperature was measured at 105 degrees Fahrenheit.

Common Areas: These included the living room and dining area. The common areas were properly furnished. The auditory alarms on all exit doors were on and functional at the time of the visit.
SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Michael CavaTELEPHONE: (818) 389-7921
LICENSING EVALUATOR SIGNATURE:
DATE: 07/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/22/2023
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: CONCORDIA ASSISTED LIVING
FACILITY NUMBER: 197610123
VISIT DATE: 07/22/2023
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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. The laundry area is located in the bedroom hallway. No cleaning supplies or laundry detergent present.

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.

Medications: Medication and Medication Records were reviewed for proper 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.
SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Michael CavaTELEPHONE: (818) 389-7921
LICENSING EVALUATOR SIGNATURE:

DATE: 07/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2023
LIC809 (FAS) - (06/04)
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