197610680-5-2-2025-31-AS-LDLC-DGANHG-20250502102840

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610680
Report Date: 03/25/2025
Date Signed: 05/02/2025 10:28:57 AM

Document Has Been Signed on 05/02/2025 10:28 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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	DAVID GOGIAN HOUSE		FACILITY NUMBER:	197610680
ADMINISTRATOR/ DIRECTOR:	FAIRMAN, VERONICA		FACILITY TYPE:	735
ADDRESS:	1239 ALMA STREET		TELEPHONE:	(818) 502-9901
CITY:	GLENDALE	STATE: CA	ZIP CODE:	91202
CAPACITY: 6		CENSUS: 4	DATE:	03/25/2025
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	02:15 PM
MET WITH:	Briana Windell,Tetyana Wynter, Mannie George		TIME VISIT/ INSPECTION COMPLETED:	04:30 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 Analyst (LPA) Leizl de la Cerra conducted a Component III and Pre-Licensing Inspection for a Change in Ownership with the applicant representatives, Briana Windell, Director of Residential Services, Tetyana Wynters VP of Member Services and the facility administrator, Mannie George. The Change in Ownership (CHOW) application to operate an Adult Residential Facility (ARF) was received by Community Care Licensing (CCL) on July 29, 2024. This is a one story facility that consist of 5 client bedrooms and 3 bathrooms. The facility is currently occupying four (04) clients. The smoke alarm and carbon monoxide detector are dual and interconnected, they were tested and observed to be operational. The facility has three fully charged fire extinguishers. A fire clearance was approved on November 21, 2024. A complete first aid kit was observed. LPA observed the required facility postings. A physical plant tour was conducted at 2:15pm, LPA was accompanied by both applicant representatives and the facility administrator, and the following was observed: KITCHEN: The facility has a kitchen area that is equipped with a stove, refrigerator and microwave oven. There was an adequate supply of perishable and nonperishable food and dining ware to accommodate a maximum capacity of six (6) clients. Knives were observed locked in a kitchen drawer. Cleaning solutions were observed inside a locked cabinet underneath the kitchen sink. BEDROOMS: There are five (5) bedrooms designated for client use. The client rooms were furnished with the following, beds with linens, night stands, desk lamps, chairs, and dressers. The bedrooms have sufficient lighting and closet space. Continue to LIC809-C

NAME OF LICENSING PROGRAM MANAGER: Naira Margaryan
NAME OF LICENSING PROGRAM ANALYST: Leizl De La Cerra
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 03/25/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/25/2025

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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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: DAVID GOGIAN HOUSE	FACILITY NUMBER: 197610680
	VISIT DATE: 03/25/2025

NARRATIVE

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Bathrooms: The facility has three (3) bathrooms. The bathrooms were observed to have the proper fixtures, grab bars, and non-skid mats. The hot water delivered in the bathrooms measured at 104.3°F to 108.7°F.

Common Areas: These included the living room and dining room area. The living room has a couch, a table and television. The dining room table is large enough to seat up to six (6) residents. There were no visible immediate hazards. The facility maintains a comfortable temperature at 71°F. The living room and dining area appeared clean.

Laundry: The washer and dryer is located by the kitchen area. Detergents and cleaning supplies are kept locked inside the staff bathroom.

Medications: Medications are properly labeled and are centrally stored in a locked medication closet located in the staff office. During the visit today, LPA reviewed clients' medications, all medication is administered according to doctor’s orders.

Resident Files: Resident files are kept in a cabinet located in the garage. The garage is kept locked. LPA conducted a file review of resident records to insure compliance of licensing forms.

Staff Files: Staff files are also kept in a locked container located in the garage. The garage is kept locked. LPA conducted a file review of staff records to insure forms and training are up to date and compliance with licensing forms.

Surrounding Grounds: The passageways and entrance to the home was clear of obstruction. The facility has outdoor furniture with a covered shaded area for clients to use. The facility does not have a swimming pool or any other bodies of water. The facility backyard has sufficient yard space.

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. CAB will be advised and a copy of this report provided.

NAME OF LICENSING PROGRAM MANAGER: Naira Margaryan
NAME OF LICENSING PROGRAM ANALYST: Leizl De La Cerra
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 03/25/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/25/2025

LIC809 (FAS) - (06/04)

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