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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610215
Report Date: 09/22/2021
Date Signed: 09/22/2021 11:21:35 AM

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:BAHAMA ASSISTED LIVING, INCFACILITY NUMBER:
197610215
ADMINISTRATOR:AVOYAN, MARIETAFACILITY TYPE:
740
ADDRESS:15851 BAHAMA STREETTELEPHONE:
(747) 236-7322
CITY:NORTH HILLSSTATE: CAZIP CODE:
91343
CAPACITY:6CENSUS: 6DATE:
09/22/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
08:15 PM
MET WITH:Karine Sarkisyan - Operator TIME COMPLETED:
10:00 PM
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Licensing Program Analyst (LPA) Yelena Avetisyan along with Ginger Perini from the Long Term Care Ombudsman's office conducted an unannounced case management visit to this facility. On 09/03/2021 an allegation of unlicensed care was substantiated at this locations at which time A NOTICE OF OPERATION IN VIOLATION OF LAW was issued to the operator Karine Sarkisyan. (Complaint Control # 31-AS-20200821094334)

Upon arrival LPA and LTCO met with staff Hasmik/Jasmine Hokinyan. Staff contacted operator Karine Sarkisyan via telephone. Operator arrived shortly after. LPA conducted a tour of the facility and confirmed that the home continues to provide care and supervision to 4 residents. Also during the visit LPA observed the home to be clean and have sufficient food supply. Approximately 8:40 am to 9:15 am LPA and LTCO conducted interview with 2 residents. At 9:15 am LPA spoke briefly with staff who reported no unusual incidents have occurred with residents since the departments 9/3/2021 visit. LPA' also spoke with the operator regarding 2 checks that were issued to a placement agent. Approximately 9:30 am LPA and LTCO spoke with Resident 1 (R1) again.

An application for RCFE license for this location; "Bahama Assisted Living Inc" was submitted by the operator and is currently pending. LPA reminded the operator Karine Sarkisyan that no new residents shall be admitted at this time (pending status). LPA also reminded the operator Karine Sarkisyan that a Notice of Operation in Violation of Law was served to her at the time of complaint investigation and that continued operation pending process of application is a violation of law, subject to civil penalties under Health and Safety Code Section 1547, 1568.0821, 1569.485, or 1596.893 b, and applicable regulations, as well as other actions by the Department. Exit interview conducted and copy of report emailed to the operator.
SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Yelena AvetisyanTELEPHONE: (818) 378-8120
LICENSING EVALUATOR SIGNATURE:

DATE: 09/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2021
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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