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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610139
Report Date: 06/10/2021
Date Signed: 06/10/2021 11:56:25 AM

Document Has Been Signed on 06/10/2021 11:56 AM - 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:ELEOS HOMES INCFACILITY NUMBER:
197610139
ADMINISTRATOR:BAGRAMYAN,MARGARITAFACILITY TYPE:
740
ADDRESS:17144 COURBET STTELEPHONE:
(323) 364-0000
CITY:GRANADA HILLSSTATE: CAZIP CODE:
91344
CAPACITY: 6CENSUS: 0DATE:
06/10/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Margarita BagramyanTIME COMPLETED:
12:00 PM
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Licensing Program Analysts (LPA) Gary Tan, Melissa Ruiz and Angela Panushkina conducted an announced Pre Licensing visit to this facility and met with applicant Margarita Bagramyan. The applicant is "Eleos Homes, Inc". Fire Clearance dated 01/21/2021 was received for six (6) non-ambulatory residents, of which one (1) may be bedridden in Room #1.

Purpose of today’s visit is to inspect the facility to ensure that the facility is in compliance with the rules and regulations of California Code of Regulations, Title 22, Division 6.

The facility is a single storey building, Today's site visit consisted of LPAs touring the physical plant inside and outside and observed the following:

The facility dual smoke/carbon monoxide alarm system is hard wired and interconnected. The fire extinguisher is located in the kitchen and was observed to be fully charged and was bought on 01/21/2021. Dual Smoke and Carbon Monoxide detectors were observed all over the facility, tested and observed to be operational. Hot water was tested in the common bathrooms and measured at 111.0°F. There is a functioning telephone on the premises. An emergency exit plan/sketch is posted on the hallway wall with other posting requirements. There are four (4) resident bedrooms, two (2) private and two (2) shared room. One (1) additional bedroom is designated for staff use. Resident bedrooms were observed to be appropriately furnished. The common areas (living room, kitchen and dining areas) were appropriately furnished and lighting was adequate. The living room has a television and comfortable furniture. Resident and staff records will be stored in a locked cabinet near the living room area. Medications will also be stored in the same locked cabinet. The first aid kit is readily available. There are three (3) 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.

(continued on LIC 809-C)

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE: DATE: 06/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/10/2021
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: ELEOS HOMES INC
FACILITY NUMBER: 197610139
VISIT DATE: 06/10/2021
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(continued from LIC 809)

The kitchen knives are stored in a locked toolbox inside the locked cabinet near the living room. Kitchen cleaning supplies are stored in a locked cabinet under the kitchen sink. Laundry detergents, cleaning supplies and other toxins are stored in the laundry area. The laundry area is located in the garage. The necessary precautions have been made to the facility to safely house dementia residents such as auditory alarms on all doors and locked areas for centrally stored medications. Facility appears to be clean and in good repair. Appliances in the kitchen appeared to be functional.

There is a sitting area in the backyard for residents to conduct outdoor activities. The backyard is fenced. The garage is attached to the house but has no access from the inside. The garage is currently being used as a laundry area, emergency and perishable food and other supplies storage. The garage was observed to be locked. There is no body of water in the facility.

Component III was conducted with the administrator.

Facility is in compliance with Title 22 Regulations at this time. This report will be forwarded to the Centralized Application Bureau (CAB). You will be notified by the CAB Analyst when your license has been approved.

Exit interview was conducted with Licensee Representative Margarita Bagramyan and a copy of this report was provided.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE:

DATE: 06/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/10/2021
LIC809 (FAS) - (06/04)
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