197610632-1-15-2025-31-AS-NSHN-DCXS78-20250115123708

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610632
Report Date: 01/15/2025
Date Signed: 01/15/2025 12:37:20 PM

Document Has Been Signed on 01/15/2025 12:37 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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	HILDA ASSISTED LIVING II		FACILITY NUMBER:	197610632
ADMINISTRATOR/ DIRECTOR:	YEGEYAN, MARY		FACILITY TYPE:	740
ADDRESS:	17183 SAN JOSE STREET		TELEPHONE:	(818) 403-1803
CITY:	GRANADA HILLS	STATE: CA	ZIP CODE:	91344
CAPACITY: 6		CENSUS:	DATE:	01/15/2025
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	10:00 AM
MET WITH:	Nazar (Nick) Yegeyan		TIME VISIT/ INSPECTION COMPLETED:	12:45 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analysts (LPAs) Nadia Shahbazian and Michael Cava conducted a Pre-Licensing Inspection with the administrator, Nazar (Nick) Yegeyan. An Application to operate a Residential Care Facility for the Elderly (RCFE) was received by Community Care Licensing (CCL) on May 13, 2024. A fire clearance was approved on December 17, 2024 for five (5) non-ambulatory residents and one (1) bedridden resident, for a total capacity of six. The licensee is requesting a hospice waiver to retain six (6) residents. The smoke alarms and carbon monoxide detectors are dual and inter-connected. The facility has a brand new fire extinguisher purchased on 01/04/25. Fire extinguisher is located at the kitchen. All the rooms have fire doors and fire sprinklers. With the assistance of both the administrator, a tour of the physical plant was initiated at 10:30am and the following was observed: KITCHEN: The facility has a Kitchen area that is equipped with a refrigerator, stove/oven, microwave oven and dishwasher. There was an adequate supply of emergency food items observed. Perishable food items not required at this time as there are no residents. Administrator was advised facility needs to carry perishable food items once they admit residents for care. Knives were observed locked in a kitchen drawer. Cleaning supplies observed locked underneath the kitchen sink. There was adequate supply of dinning ware for six (6) residents. .

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Nadia Shahbazian
LICENSING EVALUATOR SIGNATURE:	DATE: 01/15/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/15/2025

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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: HILDA ASSISTED LIVING II	FACILITY NUMBER: 197610632
	VISIT DATE: 01/15/2025

NARRATIVE

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BEDROOMS: There are four (4) bedrooms designated for client use, each with fire doors. Bedroom one (1) and two (2) are private and bedrooms three (3) and four (4) will be shared. Per STD 850, bedroom one (1) or two (2) are appropriated for bedridden resident. Each bedroom was furnished with beds, night stands, chairs, night lights, bedding and linen. The bedrooms have sufficient lighting. The bedrooms have sufficient lighting and closet space.

BATHROOMS: The facility has two (2) full bathrooms. One of the bathrooms is in the hallway between bedroom one (1) and two (2) and the other between bedrooms three (3) and four (4). The bathrooms were observed to have the proper fixtures, grab bars, non-skid mats and shower chairs. Bathrooms had adequate supply of linens and hygiene items. Hot water delivered in the bathrooms measured between 112 degrees.

COMMON AREAS: These included the living room and dining room areas. The living room has a couch, chair, table, and television. The dining room has a table large enough to seat six (6) residents. Activity area was located in the living room and there is an exit door leading to the backyard.

LAUNDRY ROOM: The laundry area is located in a separate, covered space, near room three (3) and four (4). Laundry detergents were kept locked under the kitchen sink.

MEDICATIONS: Medications will be kept in a locked cabinet near dining room.

OFFICE/STAFF WORKSTATION: Staff workstation/office is located near the dining room. There is a cabinet to store resident and staff records. Facility is equipped with internet access and land line telephone.

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Nadia Shahbazian
LICENSING EVALUATOR SIGNATURE:	DATE: 01/15/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/15/2025

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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: HILDA ASSISTED LIVING II	FACILITY NUMBER: 197610632
	VISIT DATE: 01/15/2025

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SURROUNDING GROUNDS: The front is gated and unlocked from inside. The driveway, passageways and entrance to the home was clear of obstruction. All entry and exit doors have a functional auditory alert when the doors open. The backyard is large enough to hold outdoor furniture and activities. There is no swimming pool, no garage. The side gate leading to the backyard was free of obstruction and was designated for emergency entry/exit.

In addition to the Pre-Licensing inspection, a Component III power point presentation was also held. Pursuant to Title 22, Division 6 of the CA Code of Regulations, the facility's physical environment appears to be compliant and ready for licensure. CAB will be advised and a copy of this report provided.

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Nadia Shahbazian
LICENSING EVALUATOR SIGNATURE:	DATE: 01/15/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/15/2025

LIC809 (FAS) - (06/04)

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