197610123-5-5-2024-31-AS-MCAA-D4YUDQ-20240505152956

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610123
Report Date: 05/05/2024
Date Signed: 05/05/2024 03:30:35 PM

Document Has Been Signed on 05/05/2024 03:30 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:	05/05/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:43 AM
MET WITH:	Nazar "Nick" Yegeyan		TIME COMPLETED:	12:00 PM

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) Michael Cava conducted an Annual Required visit and inspection of the facility. LPA met with the administrator, Nazar "Nick" Yegeyan and advised him of the purpose for the visit. At approximately 08:45am, 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. There is a short gate at the stairs, approximately three feet high to block entry. 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. Fire extinguisher was purchased on May 23, 2023. Licensee will either purchase new or charge date before this date. 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. 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 111 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 Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Michael Cava	TELEPHONE: (818) 389-7921
LICENSING EVALUATOR SIGNATURE:	DATE: 05/05/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2024

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: 05/05/2024

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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.

Work Station: There is a work station at the entrance where staff and resident files are maintained.

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 to insure training documents and licensing forms are in compliance.

Medications: Medication cabinet is maintained at the staff work station. 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 Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Michael Cava	TELEPHONE: (818) 389-7921
LICENSING EVALUATOR SIGNATURE:	DATE: 05/05/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2024

LIC809 (FAS) - (06/04)

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