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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610401
Report Date: 04/13/2023
Date Signed: 04/13/2023 10:54:52 AM

Document Has Been Signed on 04/13/2023 10:54 AM - 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:KDAD INC. 2FACILITY NUMBER:
197610401
ADMINISTRATOR:ADAMYAN, ARMINEFACILITY TYPE:
735
ADDRESS:15033 BROADMOOR STREETTELEPHONE:
(818) 326-4433
CITY:NORTH HILLSSTATE: CAZIP CODE:
91343
CAPACITY: 4CENSUS: 0DATE:
04/13/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Armine Adamyan TIME COMPLETED:
11:15 AM
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On 4/13/2023 at 9:30 a.m., Licensing Program Analysts (LPA) Melissa Ruiz conducted an announced Pre-Licensing visit to this facility and met with applicant Armine Adamyan. This is an initial application, a fire clearanced was received for four (4) clients. The purpose of today’s visit is to inspect the facility to ensure that it compliant under California Code of Regulations, Title 22, Division 6. This application is for an Adult Residential Facility, licensed for 4 clients, level 3 and will be vendored with North Los Angeles Regional Center.

Today’s site visit consisted of LPA touring the physical plant inside and outside and observed the following:

The facility has dual carbon monoxide and smoke alarm system which was tested at 9:50 a.m. and was deemed operational. There is a fire extinguisher, which appears to be fully charged. There is a functioning telephone on the premises. An emergency exit plan/sketch is posted along the hallways with other posting requirements. There are four bedrooms, 1 of which is shared, 2 are private, and one designated for staff. Resident bedrooms were observed to be appropriately furnished. The common areas (living room, kitchen, and dining areas) were appropriately furnished, and lighting was adequate. The living room has a television and comfortable furniture. Resident and staff records will be stored in a locked cabinet near the kitchen. Medications will be also centrally stored in the same locked cabinet. The first aid kit is readily available with the manual. Two out three bathrooms have non-skid mats. Trash cans had closed tight fitting lids throughout.

(CONT. on LIC809-C)

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Melissa Ruiz
LICENSING EVALUATOR SIGNATURE: DATE: 04/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/13/2023
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: KDAD INC. 2
FACILITY NUMBER: 197610401
VISIT DATE: 04/13/2023
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The kitchen knives will be in a locked cabinet. The chemicals and cleaning supplies are stored and locked in the laundry closet. Facility appears to be clean and in good repair. Appliances in the kitchen appeared to be functional. There are various sitting areas in the backyard that are shaded. The backyard is fenced. There is no garage. There is a shed that is kept locked outside. On the property there is another dwelling, which is licensed and permitted. LPA reviewed the Certificate of Occupancy.

Component III was waived with applicant, since applicant has another facility.

This report will be forwarded to the Centralized Application Bureau (CAB). You will be notified by the CAB Analyst when your license has been approved. Exit interview was conducted with Licensee. A copy of this report was signed and delivered.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Melissa Ruiz
LICENSING EVALUATOR SIGNATURE:

DATE: 04/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/13/2023
LIC809 (FAS) - (06/04)
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