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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610124
Report Date: 04/08/2022
Date Signed: 04/08/2022 12:18:48 PM

Document Has Been Signed on 04/08/2022 12:18 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 RESIDENTIAL CAREFACILITY NUMBER:
197610124
ADMINISTRATOR:YEGEYAN, NAZARFACILITY TYPE:
740
ADDRESS:16706 BLACKHAWK STREETTELEPHONE:
(818) 403-1803
CITY:GRANADA HILLSSTATE: CAZIP CODE:
91344
CAPACITY: 6CENSUS: 5DATE:
04/08/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Nexzar Yegeyan/ AdministratorTIME COMPLETED:
12:45 PM
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Licensing Program Analyst (LPA), Patrick Shanahan, arrived at the facility and was greeted by facility staff. Staff was observed wearing a mask and took the LPA's temperature before allowing the LPA into the facility.

LPA was able to briefly tour the facility for health and safety concerns. All smoke alarms were tested functioned properly. The carbon monoxide detector was tested and functioned properly. The fire extinguisher was last purchased on 3/30/2022.

The facility is currently following their mitigation plan and no deficiencies were observed during todays visit.

Exit interview conducted and report issued.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Patrick Shanahan
LICENSING EVALUATOR SIGNATURE: DATE: 04/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/08/2022
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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