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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610337
Report Date: 05/19/2024
Date Signed: 05/19/2024 03:36:30 PM

Document Has Been Signed on 05/19/2024 03:36 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:NH CARE, LLCFACILITY NUMBER:
197610337
ADMINISTRATOR/
DIRECTOR:		KOSOYAN, GRIGORFACILITY TYPE:
740
ADDRESS:15757 SEPTO STREETTELEPHONE:
(818) 919-9181
CITY:NORTH HILLSSTATE: CAZIP CODE:
91343
CAPACITY: 6CENSUS: 3DATE:
05/19/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:00 PM
MET WITH:Davit ManucharyanTIME VISIT/
INSPECTION COMPLETED:
03:45 PM
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Licensing Program Analyst (LPA), Tihesha Smith conducted an unannounced Required 1-year inspection at this facility at 12:00 pm. LPA contacted the administrator for point of entry. The administrator was present at the facility and came to the front gate.

LPA conducted a tour of the physical plant at approximately to ensure there are no health and safety hazards and facility is following Title 22 Regulations.

Common areas were observed for the ability to safely serve the needs of residents. These included the kitchen and living room/dining area combination. The common areas were checked for cleanliness and furniture was checked for functionality. Common areas observed to be furnished appropriately with adequate seating for residents.

LPA reviewed the food service areas, food storage and supply (perishable and nonperishable foods). The
kitchen food supply was observed. There is sufficient for the three (3) residents currently residing there. Two (2) days of perishable food observed. The freezer is stocked with meats and frozen vegetables. Sharps are stored in locked cabinet in kitchen island. The resident medications are stored in locked upper cabinet in the kitchen. The medication and sharps were observed to be locked and inaccessible to residents. The first aid kit is stored in hall closet #1/pantry.

Laundry room is located outside in shed. The appliances observed new, clean, and functional. Toxins under kitchen sink and observed to be locked and inaccessible to residents. There is one (1) fire extinguisher: attached to the kitchen wall observed to be charged.
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Tihesha Smith
LICENSING EVALUATOR SIGNATURE: DATE: 05/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/19/2024
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: NH CARE, LLC
FACILITY NUMBER: 197610337
VISIT DATE: 05/19/2024
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(Cont. from 9099)

The facility has a total of three (3) bedrooms for residents and two (2) bathrooms for residents’ use. The resident bedrooms were properly furnished with at least one chair, nightstand, and sufficient lighting for each resident. The bedrooms had appropriate and adequate bedding and linens such as sheets, pillowcases, mattress pads, and blankets. LPA observed a supply of linens in hallway closet #3.

Each bathroom has the following items available: hand soap, paper towels, and trash cans. The hot water temperature was measured for the two (2) bathrooms to ensure it is within the required range for residents’ comfort and safety. The water temperature range was between 115.2 and 115.9 degrees Fahrenheit.

The backyard has the following: Gazebo, with table and sufficient seating for the residents. Patio furniture observed to be in good repair. There are two (2) sheds used for storage and extra food replenishment.
Garage: no garage at the facility.

Smoke detectors and Carbon Monoxide detectors were tested and operable at time of visit.

Facility grounds were free of hazards. There is no body of water in the facility. There were no immediate
health and safety hazard observed during the day of inspection.

Yard growth being used for mulch/active work noted.

At approximately 1:05 pm, LPA reviewed facility records. Current insurance policy on file. Administrator has current license to include CPR/First aid. Resident records have admissions agreements, Pre appraisal and physician reports.

No citations issued.

Exit Interview Conducted / A Copy of the Report given.
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Tihesha Smith
LICENSING EVALUATOR SIGNATURE:

DATE: 05/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2024
LIC809 (FAS) - (06/04)
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