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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610222
Report Date: 01/14/2022
Date Signed: 01/14/2022 11:26:46 AM

Document Has Been Signed on 01/14/2022 11:26 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:KINGSBURY STREET HOME, INC.FACILITY NUMBER:
197610222
ADMINISTRATOR:SARKISYAN, JOHNNYFACILITY TYPE:
740
ADDRESS:16457 KINGSBURY STREETTELEPHONE:
(818) 519-8080
CITY:GRANADA HILLSSTATE: CAZIP CODE:
91344
CAPACITY: 6CENSUS: 0DATE:
01/14/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Johnny Sakisyan/ AdministratorTIME COMPLETED:
11:45 AM
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Licensing Program Analyst (LPA), Patrick Shanahan, conducted an announced pre-licensing visit on this day. The Component III was also completed during todays visit.

The facility is a six bedroom, single-story home licensed to care for 5 non ambulatory clients and 1 bedridden. LPA was greeted upon arrival and confirmed that COVID screening protocols are in place at the facility.

LPA utilized the Residential Care Facility for the Elderly (RCFE) Prelicensing inspection tool to verify compliance with all inspection domains. The facility's common areas and bedrooms/bathrooms were clean, well-furnished and functional. Facility appliances were in working condition, hot water temperature measured between 105 and 120 degrees, and appropriate storage areas were present for cleaning supplies, medications and other hazardous materials. Smoke alarms and carbon monoxide detectors were tested and all were functional

No deficiencies observed during this visit.

This report will be sent to the Centralized Application Bureau (CAB) You will be notified by the CAB Analyst when your license has been approved. You are not allowed to begin operating until you have been notified that your license has been approved by the CAB analyst. Failure to comply could affect approval of your license
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Patrick Shanahan
LICENSING EVALUATOR SIGNATURE: DATE: 01/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/14/2022
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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