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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603270
Report Date: 02/07/2022
Date Signed: 02/07/2022 04:20:35 PM

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:GRANT SERENITY HOMES OF PASADENA, INC.FACILITY NUMBER:
198603270
ADMINISTRATOR:GEVORKIAN, NVARDFACILITY TYPE:
740
ADDRESS:1745 WAGNER STREETTELEPHONE:
(818) 425-6797
CITY:PASADENASTATE: CAZIP CODE:
91106
CAPACITY:6CENSUS: 6DATE:
02/07/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:46 PM
MET WITH:Lida Gasparyan - Caregiver
Nvard Gevorkian - Administrator
TIME COMPLETED:
04:00 PM
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Licensing Program Analyst(s) Mary Flores conducted an unannounced annual visit at the facility with focus on the infection control domain, medication and food review. LPA Flores met with Lida Gasparyan caregiver and explained the reason for the visit. Administrator Nvard Gevorkian arrived 20 minutes later.

The facility is licensed to served 6 non-ambulatory residents age range 60 and over, of which 1 may be bedridden and hospice waiver for 2. The facility has 6 bedrooms, 1 bathroom, a dining room, a living room, a detached garage, a detached laundry room, a back patio and a front yard. Facility has interlace smoke/carbon monoxide detectors that were tested during the visit and in working condition.

LPA Flores conducted the tour with Lida Gasparyan caregiver at 12:45pm and observed the following:
Kitchen area: has sufficient food supplies for at least 2 days of perishables and 7 days of non-perishables. Sharps were observed locked in a drawer to the left of kitchen's sink and chemical solutions were locked under kitchen's sink. Dining and living room have sufficient lighting and sitting area, Medication cabinet was observed under lock in the dining room. All bedrooms have all required furniture, lighting, and bedding. Bathroom #1 was observed with grab bars, shower mat, and water temperature was tested at 111.7 degrees F., which is within the required 105-120 degrees F. Fire extinguisher was observed outside the kitchen and read full. LPA observed emergency food supplies and PPE supplies in the garage. LPA reviewed medication for resident #1(R1) and #2(R2) and reviewed files for R1, R2, and staff #1(S1) and #2(S2). LPA observed administrator certificate for Nvard Gevorkian #6050643740 expiration date: 12/23/22.
Facility is following COVID 19 recommendations regarding screening visitors, staff, and residents. Signs are posted throughout the facility, and hand-washing sign was observed in bathroom, sufficient hand soap, hand sanitizer, and paper towels were observed. Staff have not been fit test for N95 administrator will schedule fit testing a technical assistance has been noted.
No deficiencies were given during this visit. Exit interview was conducted with Nvard Gevorkian administrator a copy of this report was email for signature due to LPA unable to access computer at the time of the visit.
SUPERVISOR'S NAME: Stefanie CoronelTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:

DATE: 02/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/07/2022
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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