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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610306
Report Date: 10/05/2022
Date Signed: 10/05/2022 01:13:48 PM


Document Has Been Signed on 10/05/2022 01:13 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, 744 P STREET, MS 9-14-8201
SACRAMENTO, CA 95814



FACILITY NAME:ASSISTED SENIOR CARE FACILITYFACILITY NUMBER:
197610306
ADMINISTRATOR:AGHABEKYAN, GAYANEFACILITY TYPE:
740
ADDRESS:7039 CLAIRE AVETELEPHONE:
(818) 578-5958
CITY:RESEDASTATE: CAZIP CODE:
91335
CAPACITY:6CENSUS: DATE:
10/05/2022
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Gayane Aghabekyan & Bagrat VahramyanTIME COMPLETED:
12:25 PM
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Facility Type: RCFE
Application Type: CHOW
Capacity: 6
Census (if any clients in care): 5
Method: Telephone call with CAB
COMP II Participants: Gayane Aghabekyan & Bagrat Vahramyan

Applicant/administrator participated in COMP II via telephone call with the analyst at CAB. Identification of the applicant and administrator was verified by photo ID. During COMP II, applicant and administrator confirmed the understanding of Title 22. Component II was successfully completed. Applicant has been advised to transmit signed LIC 809 with copy of photo ID to CAB.
SUPERVISOR'S NAME: Julia KimTELEPHONE: (916) 651-7848
LICENSING EVALUATOR NAME: Dianne RamosTELEPHONE: (916) 653-5973
LICENSING EVALUATOR SIGNATURE:
DATE: 10/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/05/2022
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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