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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610124
Report Date: 12/22/2023
Date Signed: 12/22/2023 03:21:09 PM


Document Has Been Signed on 12/22/2023 03:21 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: 4DATE:
12/22/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:28 PM
MET WITH:Anna Bludova, Nazar YegeyanTIME COMPLETED:
03:30 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, Anna Bludova and explained the reason for the visit. The administrator, Nazar Yegeyan joined shortly after.

At approximately 12:45am, with the assistance of staff, LPA took a tour of the physical plant. Required postings were observed in the entry area. The facility dual smoke/carbon monoxide alarm system is hard wired and interconnected. The fire extinguisher is located in the kitchen and observed to be fully charged and was bought on 07/22/23. 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.

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 three (3) bedrooms designated for residents' use. All three bedrooms are shared rooms. All three bedrooms were properly furnished with appropriate beddings and linens with sufficient lighting.

Bathrooms: There are two (2) bathrooms designated for residents' use. Both bathrooms were properly supplied and had functional fixtures. Hot water temperature was measured at 114 degrees Fahrenheit. No cleaning supplies were observed in the bathrooms during the day of the visit.

Common Areas: These included the living room and dining area. The common areas were properly furnished. The dining room table is large enough to accommodate up to six residents. Floors were clean and in good repair. The auditory alarms on all exit doors were on and functional at the time of the visit. Exits/entrance were clear of obstruction.
SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Michael CavaTELEPHONE: (818) 389-7921
LICENSING EVALUATOR SIGNATURE:
DATE: 12/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/22/2023
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 RESIDENTIAL CARE
FACILITY NUMBER: 197610124
VISIT DATE: 12/22/2023
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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. Laundry detergents, cleaning supplies and other toxins are stored in the locked cabinet.

Resident Files: Files are kept in a locked cabinet in the kitchen. LPA conducted a file review of resident records to insure compliance of licensing forms.

Staff Files: Files are kept in a locked cabinet in the kitchen. LPA also conducted a file review of staff records to insure forms and training are up to date and compliance with licensing forms.

Medications: Medications are kept in a locked cabinet in the kitchen. Medications and Medication Records were review for storage and 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: 12/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2