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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320319
Report Date: 08/29/2024
Date Signed: 08/30/2024 10:10:54 AM

Document Has Been Signed on 08/30/2024 10:10 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
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME:BEVERLY HILLS HOMEFACILITY NUMBER:
198320319
ADMINISTRATOR/
DIRECTOR:		GHODSIAN, SHAROUZFACILITY TYPE:
772
ADDRESS:450 SOUTH LA PEER DRIVETELEPHONE:
(310) 709-7355
CITY:BEVERLY HILLSSTATE: CAZIP CODE:
90211
CAPACITY: 6CENSUS: 0DATE:
08/29/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:23 AM
MET WITH:Sharouz Ghodsian, AdministratorTIME VISIT/
INSPECTION COMPLETED:
11:30 PM
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On 08/29/24, Licensing Program Analyst (LPA) Felisa Shirley conducted an unannounced required annual visit using the full CAREs Inspection Tool. LPA met with Administrator, Sharouz Ghodsian and explained the purpose of today’s visit. The facility is licensed to serve 6 ambulatory short term residents. During the time of visit there are no clients.

LPA Felisa and Sharouz toured both inside and outside of the facility. The facility is a one-story structure located in a residential neighborhood. The facility consists of (3) client bedrooms, (3) bathroom, living room, kitchen, dining area, patio, and laundry room. Facility maintains all required posting throughout the facility. LPA reviewed copy of the Liability insurance.

All bedrooms were toured. Bedrooms 1-3 are for the residents and contain the mandated furniture. LPA observed all rooms to have the required furniture including a bed, dresser(s), nightstand, and chair(s). All beds had the required linens including a mattress cover, fitted sheets, blanket, comforter, and pillow. LPA observed ample lighting in all the bedrooms.

LPA Shirley and Sharouz toured the kitchen and found it to be clean and sanitary. All appliances were in good working order. Knives were locked and stored. LPA observed a 3-day supply of perishable and a 7-day supply of nonperishable foods. The water temperature measured 111 degrees Fahrenheit. The bathrooms are clean and operational. First aid kit is fully stocked with manual. No firearms are stored at facility and no bodies of water present. This facility is in good repair.

LPA Shirley and Sharouz walked through all common areas. In the living room, kitchen, dining room there is ample seating and space for all residents. All rooms and walkways were clean, and clear of obstructions and hazards.

Con'd on 809-C

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE: DATE: 08/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/29/2024
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
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: BEVERLY HILLS HOME
FACILITY NUMBER: 198320319
VISIT DATE: 08/29/2024
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All areas have ample lighting. All rooms, hallway, and living room have working smoke detectors. There is a charged fire extinguisher in the kitchen. The backyard is clean and clear of obstructions and hazards, shaded patio area and there are no bodies of water present.


An exit interview was conducted, and a copy of this report was provided to Administrator, Sharouz Godsian.
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE:

DATE: 08/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2024
LIC809 (FAS) - (06/04)
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