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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610345
Report Date: 03/12/2024
Date Signed: 03/12/2024 01:49:29 PM


Document Has Been Signed on 03/12/2024 01:49 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:HILDA ASSISTED LIVINGFACILITY NUMBER:
197610345
ADMINISTRATOR:YEGEYAN, MARYFACILITY TYPE:
740
ADDRESS:17179 SAN JOSE STREETTELEPHONE:
(818) 403-1803
CITY:GRANADA HILLSSTATE: CAZIP CODE:
91344
CAPACITY:6CENSUS: 6DATE:
03/12/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:14 AM
MET WITH:Nazar YegeyanTIME COMPLETED:
02:00 PM
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Licensing Program Analysts (LPAs) Michael Cava conducted an Annual Required visit and inspection of the facility. LPA met with the administrator, Nazar Yegeyan and explained the reason for the visit.

At 10:20am, with the assistance of the administrator, LPA took a tour of the physical plant. Required postings were observed in the entry area. The smoke alarms and carbon monoxide are dual and interconnected. The fire extinguisher is located by the kitchen. It was purchased July 11, 2023.

Kitchen: The kitchen appliances and fixtures were functional. LPA found a sufficient amount of perishable and non-perishable food at the facility; properly stored. Licensee also maintains two buckets of emergency food supply, serves up to 92 servings, and good for twenty-five years kept in the facility. Knives were stored locked in a kitchen drawer. Properly labeled medications were locked in one of the kitchen cabinets.

Bedrooms: There were four (4) bedrooms designated for residents' use. Two rooms are private, and two bedrooms are shared. All four bedrooms were observed properly furnished with appropriate beddings and linens with sufficient lighting.

Bathrooms: There are two (2) bathrooms designated for residents' use. Both bathrooms were properly supplied and had functional fixtures. Hot water temperature was measured at 110.7 degrees Fahrenheit. There were no cleaning supplies observed accessible to the residents during the day's inspection. Cleaning supplies are kept locked underneath the kitchen sink.

Common Areas: These included the living room and dining area. The common areas were properly furnished. The auditory alarms on all exit doors were on and functional at the time of the visit. The floors were clean and mopped. The indoor furniture were in good repair. Passageways were clear of obstruction.
SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Michael CavaTELEPHONE: (818) 389-7921
LICENSING EVALUATOR SIGNATURE:
DATE: 03/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/12/2024
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: HILDA ASSISTED LIVING
FACILITY NUMBER: 197610345
VISIT DATE: 03/12/2024
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Surrounding Grounds: Entry/exits were free of obstruction. There was backyard furniture appropriate for outdoor use. The outdoor area was free of hazards. The laundry area is located in the hallway by resident room #4. No detergents present.

Resident Files: Resident files were kept in a cabinet by the dining room. LPAs conducted a file review of resident records to insure compliance of licensing forms.

Staff Files: Staff files are also kept in a cabinet by the dining room. LPAs also conducted a file review of staff records to insure forms and training are up to date and compliance with licensing forms.

Medications: Medication and Medication Records were review for 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 this Report Issued.
SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Michael CavaTELEPHONE: (818) 389-7921
LICENSING EVALUATOR SIGNATURE:

DATE: 03/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2024
LIC809 (FAS) - (06/04)
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