197610222-2-23-2024-31-AS-MCAA-D2QVBG-20240223151732

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610222
Report Date: 02/23/2024
Date Signed: 02/23/2024 03:18:22 PM

Document Has Been Signed on 02/23/2024 03:18 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:	KINGSBURY STREET HOME, INC.		FACILITY NUMBER:	197610222
ADMINISTRATOR:	SARGSIAN, HARUT		FACILITY TYPE:	740
ADDRESS:	16457 KINGSBURY STREET		TELEPHONE:	(818) 519-8080
CITY:	GRANADA HILLS	STATE: CA	ZIP CODE:	91344
CAPACITY:	6	CENSUS: 6	DATE:	02/23/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:25 PM
MET WITH:	Harut Sargsian		TIME COMPLETED:	03:30 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Michael Cava conducted an Annual Required visit and inspection of the facility. LPA met with the administrator, Hamut Sargsian and explained the reason for the visit. Staff, Haykuhi Nersisyan and Karine Safaryan were also present during the inspection. At approximately 12:30pm, with the assistance of staff and the administrator, LPA took a tour of the physical plant. Required postings were observed in the entry area. The smoke alarms and carbon monoxide detectors are dual, hardwired and interconnected. The fire extinguisher is located in the kitchen. It was just purchased on 02/01/24. Kitchen: The kitchen appliances and fixtures were functional. LPA found a sufficient amount of perishable and non-perishable food at the facility; properly stored. Knives were stored in a locked drawer in the kitchen. No cleaning supplies observed out in the open, or accessible to the residents. Bedrooms: There were six (6) bedrooms designated for residents' use. All six bedrooms are for private use. All six bedrooms are properly furnished with appropriate beddings and linens with sufficient lighting. Bathrooms: There are three (3) bathrooms designated for residents' use. All bathrooms were properly supplied and had functional fixtures. Hot water temperature was measured at 105 degrees Fahrenheit. Bathrooms were clear of any cleaning supplies and toxins. Common Areas: These included the living room and dining area. The common areas were properly furnished. The dining room table is large enough to seat six (6) residents. Floors were clean and furniture is in good repair.

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Michael Cava	TELEPHONE: (818) 389-7921
LICENSING EVALUATOR SIGNATURE:	DATE: 02/23/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2024

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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: KINGSBURY STREET HOME, INC.	FACILITY NUMBER: 197610222
	VISIT DATE: 02/23/2024

NARRATIVE

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Surrounding Grounds: Entry/exits were free of obstruction. There was furniture in the backyard appropriate for outdoor use. The outdoor area is large enough to hold outdoor activities and is observed free of hazards. The laundry area is located by the kitchen. The garage is attached to the home, opposite the laundry area and kitchen. Garage is inaccessible to the residents. It is used as storage area.

Staff/office: There is a staff office located at the corner of the living room area where staff and resident files are kept

Resident Files: LPA conducted a file review of resident records to insure compliance of licensing forms.

Staff Files: LPA conducted a file review of staff records to insure forms and training are up to date and compliance with licensing forms.

Medications: Medications are stored in a locked in a closet near the living room. Medications and medication records were reviewed for appropriate storage and proper documentation.

Pursuant to Title 22 Division 6 of the CA Code of Regulations, there were no deficiencies observed during the visit. Exit Interview Conducted and A Copy of the Report Issued.

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Michael Cava	TELEPHONE: (818) 389-7921
LICENSING EVALUATOR SIGNATURE:	DATE: 02/23/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2024

LIC809 (FAS) - (06/04)

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