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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610214
Report Date: 11/20/2024
Date Signed: 11/20/2024 04:55:46 PM

Document Has Been Signed on 11/20/2024 04:55 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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:DE GARMO HOMEFACILITY NUMBER:
197610214
ADMINISTRATOR/
DIRECTOR:		ASATROYAN, LUSINEFACILITY TYPE:
735
ADDRESS:8356 DE GARMO AVETELEPHONE:
(747) 223-2843
CITY:SUN VALLEYSTATE: CAZIP CODE:
91352
CAPACITY: 4CENSUS: 3DATE:
11/20/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:57 AM
MET WITH:Marieta Petrosyan, AdministratorTIME VISIT/
INSPECTION COMPLETED:
02:45 PM
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On 11/20/2024 Licensing Program Analyst (LPA) de la Cerra arrived at the facility listed above to conduct an unannounced annual inspection. LPA was greeted by Administrator, Marieta Petrosyan and explained the reason for the visit.

At approximately 10:30AM LPA and the administrator toured the physical plant of the facility, and the following was observed.
This is an Adult Residential Facility(ARF), level 2 with an approved fire clearance for four (4)ambulatory clients.
Kitchens: The kitchen was observed to be clean and clear of clutter. Appliances were functioning properly. LPA observed a sufficient amount of 2-day perishable and 7-day non-perishable supply of food and were properly stored. LPA observed knives kept in a locked kitchen drawer. Trash bin was has a covered lid.

Living rooms: The facility has two(2) living rooms available for client use. Both living rooms were clean and properly furnished. One living room has a fireplace was observed to be closed and secured.

Bathrooms: The facility has three (3) full bathrooms, 2 bathrooms are for client use and one (1) bathroom for staff use. The LPA took hot water temperature in both of the client bathrooms and temperature read between 110 degrees Fahrenheit and 117.5 degrees Fahrenheit, which is within regulation. LPA observed both bathrooms to be clean and properly supplied with toilet paper, hand soap, paper towels and trash bins with lids. LPA also observed both client bathrooms have the appropriate non-slip mats and grab bars,

Continued on to LIC809-C
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Leizl De La Cerra
LICENSING EVALUATOR SIGNATURE: DATE: 11/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/20/2024
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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: DE GARMO HOME
FACILITY NUMBER: 197610214
VISIT DATE: 11/20/2024
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Bedrooms: There are a total of four(4) bedrooms, one (1) of which are designated for staff. LPA inspected all three (3) client bedrooms. Bedroom #3 is a shared bedroom, only one(1) client is currently occupying bedroom #3, bedroom #1 is designated for only one (1) client and bedroom #2 is designated for only one (1) client . LPA observed all rooms to be properly furnished with a bed, appropriate night stand, lamp, chair, clean beddings, sufficient lighting and a walk in closet in all three (3) rooms. LPA observed extra linens in the hallway outside the bedrooms.

Garage: Garage is attached to the main house and is accessible through a separate door by the front entrance walkway. LPA observed the washer and dryer in the garage and were observed operational. Detergents, extra cleaning supplies where observed locked in a closet in the laundry room.

Surrounding Grounds:There is a covered patio area with appropriate furniture for clients to use. There are no bodies of water at this facility. LPA observed a locked shed in the backyard and is inaccessible to clients.

LPA observed the smoke alarms and Carbon Monoxide sensors are installed throughout the facility, hardwired, and interconnected. Smoke and Carbon monoxide detectors were tested at 12:45PM and observed to function properly. Fire extinguisher was fully charged and recently inspected on 10/19/2024. LPA observed required facility postings in the hallway. The first aid kit was complete. Client medications and facility files are in a locked cabinet located in the bedroom hallway. LPA observed the facility telephone on the living room and is operational.

Facility Records: At 1:00PM LPA conducted records review of facility staff and clients. LPA reviewed three (3) out three (3) client records and two (2) staff records were reviewed to insure compliance.

Medications: At approximately 2:00PM medications and medication records were reviewed for proper documentation. Centrally Stored Medication Records are pre-filled by pharmacy and facility keeps a Medication Administration Record (MAR).

Administrative: LPA collected a copy of Certificate of Liability Insurance effective until 10/17/25, copy of Surety Bond effective until 7/21/2025, LIC500 and LIC9020.

No deficiencies cited during today's visit. Exit interview conducted and copy of this report signed and delivered.

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Leizl De La Cerra
LICENSING EVALUATOR SIGNATURE:

DATE: 11/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2024
LIC809 (FAS) - (06/04)
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