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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610191
Report Date: 04/18/2022
Date Signed: 04/18/2022 12:03:36 PM

Document Has Been Signed on 04/18/2022 12:03 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:GARDENS AT NORTHRIDGE, THEFACILITY NUMBER:
197610191
ADMINISTRATOR:KESHISHYAN,VARSENIKFACILITY TYPE:
741
ADDRESS:17650 WEST DEVONSHIRE STREETTELEPHONE:
(818) 886-1616
CITY:NORTHRIDGESTATE: CAZIP CODE:
91325
CAPACITY: 135CENSUS: 68DATE:
04/18/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Varsenik Keshishyan TIME COMPLETED:
12:15 PM
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On 04/18/2022 at 9:50 a.m Licensing Program Analyst (LPA) Joscelyn Martinez arrived to conduct an announced Pre-Licensing visit to the facility and met with administrator Varsenik Keshishyan. This is a change of ownership application from (LIC 197610016) to (LIC 197610191). LPA conducted an entrance interview with Administrator. Application was received for a total of 135 residents of which 125 may be non-ambulatory. Fire clearance was approved all first-floor bedrooms for bedridden residents. Facility has sprinklers located throughout the building. The purpose of today’s visit is to inspect the facility to ensure that the facility is in compliance with rules and regulations under California Code of Regulation, Title 22, Division 6. The facility is a two-story building with an assisted living and memory care unit. Today’s site visit consisted of LPA touring the physical plant inside and outside and observed the following:

The facility has a total of twenty-four (24) bedrooms in memory care and ninety (90) bedrooms in assisted living. Bedroom toured was observed to be properly furnished. Showers in the memory care unit are located outside residents’ room to assist with bathing. Hot water was tested and measured at 119 F. Bathrooms have appropriate grab bars and non-skid mats.

The common areas were toured and were properly furnished with adequate lighting. Facility has a theater room, hair salon, and reading area for residents. Fire extinguishers are located throughout the facility and have a service date of 10/14/2021. Facility fire and carbon monoxide are hardwired and located throughout the building. LPA obtained a copy of annual fire alarm and carbon monoxide testing. Fire alarm testing was last conducted on 09/28/2021. Facility maintains a temperature of 73 degrees Fahrenheit. There is a functioning telephone on the premises. An emergency exit plan/sketch is posted by the entrance wall with other posting requirements. These postings are also posted inside the memory care unit. Medications are stored inside a medication rooms that are inaccessible to residents.

Continue on 809-C

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Joscelyn Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 04/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/18/2022
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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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: GARDENS AT NORTHRIDGE, THE
FACILITY NUMBER: 197610191
VISIT DATE: 04/18/2022
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The first aid kit is readily available. There are laundry rooms on each floor and unit. Cleaning chemicals are centrally stored in a locked room. The facility has a separate kitchen area. LPA toured kitchen and observed sufficient seven-day non-perishable and two-day perishable food for all residents. Facility was observed to be clean and in good repair.

The outside area was toured, and LPA observed appropriate furniture and shaded area for residents. There are no bodies of water.

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

Component III was conducted with the administrator. Exit interview conducted report signed and delivered.

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Joscelyn Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 04/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2022
LIC809 (FAS) - (06/04)
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