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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610248
Report Date: 05/10/2022
Date Signed: 05/10/2022 05:52:59 PM


Document Has Been Signed on 05/10/2022 05:52 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:VELVET CAREFACILITY NUMBER:
197610248
ADMINISTRATOR:BERGHOUDIAN, JACK JFACILITY TYPE:
740
ADDRESS:15731 LEMARSH ST.TELEPHONE:
(818) 891-9186
CITY:NORTH HILLSSTATE: CAZIP CODE:
91343
CAPACITY:6CENSUS: 4DATE:
05/10/2022
TYPE OF VISIT:OfficeUNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Administrator Jack Berghoudian, Applicant Representative and current Operating Manager Naira Paroyan, Applicant Representative Hayk Kirakosyan
TIME COMPLETED:
06:30 PM
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A Noncompliance Conference was conducted on this date with the following attendees: Licensing Program Analyst (LPA) Yelena Avetisyan, Licensing Program Manager (LPM) Eva Miller, Acting Regional Manager Nichelle Gillyard, Administrator Jack Berghoudian, Applicant Representative and current Operating Manager Naira Paroyan, Applicant Representative Hayk Kirakosyan

The purpose of the conference was to address chronic severe noncompliance with applicable laws rules and regulations under the Administration of Jack B. A noncompliance conference was held on 11/9/21 resulting in an agreement by the Administrator to comply with applicable laws rules and regulations. A citation for a violation of CCR 87405(a) “Administrator – Qualifications and Duties” was issued with a plan of correction agreeing that the Administrator would provide verification of training from an approved vendor for subject matter including reporting requirements, medications as well as other pertinent topics. The proof of correction is still pending.

Licensee Representative Ara A participated via telephone and advised that he had sold the corporation “Velvet Care” to Hayk K on or about 11/2/21 and that an application for an RCFE License was forthcoming. CCL received the application on 1/3/22 (Pending License # 197610248), it is still pending. Hayk K and Naira P are currently in charge of the day to day operation of the facility pending receipt of a license.

The citation for Administrator Qualifications was issued on the Annual Visit Report.

Exit interview conducted and copies of report issued
SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Yelena AvetisyanTELEPHONE: (818) 378-8120
LICENSING EVALUATOR SIGNATURE:
DATE: 05/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/10/2022
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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