<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602404
Report Date: 10/03/2023
Date Signed: 10/03/2023 11:43:37 AM


Document Has Been Signed on 10/03/2023 11:43 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, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754



FACILITY NAME:GAYANE'S SAFE HEAVENFACILITY NUMBER:
198602404
ADMINISTRATOR:KRDANYAN, GAYANEFACILITY TYPE:
740
ADDRESS:253 MAIDEN LANETELEPHONE:
(323) 823-2170
CITY:MONTEBELLOSTATE: CAZIP CODE:
90640
CAPACITY:6CENSUS: 4DATE:
10/03/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Gayane KrdanyanTIME COMPLETED:
12:00 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) Glenn Trueman made an unannounced visit and was greeted by Administrator Gayane Krdanyan.
The purpose of the visit is to complete the required inspection. .
LPA Trueman toured the facility along with Administrator Gayane Krdanyan today 10/03/2023 at 9:30 AM and the following was observed:
Facility contains 3 Resident Bedrooms and 2 Resident Bathrooms, dining room, living room, TV room, and laundry room.
Required Annual Inspection included Infection Control Practices, Operational Requirements, Physical Plant/ Environmental Safety, Staffing, Personnel Records/ Staff Training, Resident Records/ Incident Reports, Resident Rights/Information, Food Service, Planned Activities, Incidental Medical and Dental, Disaster Preparedness, and Residents with Special Health Needs.
LPA observed sufficient supply of 2 day perishables and 7 day non perishables.
All staff were cleared and associated.
Residents are encouraged to maintain and develop their fullest potential for independent living through participation in planned activities.
Visitation signage was posted along with signage for hand washing and proper sanitizing.
Licensee maintained an individual admission agreement for each client.
Fire Clearance has been maintained.
Carbon monoxide detector was observed in the facility.
Each client has personal rights free from corporal or unusual punishment, infliction of pain, humiliation, ridicule, coercion, threats, mental abuse, or other actions of a punitive nature.
Facility was clean, safe, sanitary, and in good repair at all times for the safety and well being of residents, employees and visitors.
Medication was reviewed and was given per physician's directions.
3 Resident Files and 10 Staff Files were reviewed.
Interviews were conducted with 1 Staff . All 4 residents were at Day Program.
No deficiencies.
Exit interview conducted and copy provided.

SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Glenn TruemanTELEPHONE: (323) 981-1652
LICENSING EVALUATOR SIGNATURE:
DATE: 10/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/03/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1