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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603412
Report Date: 10/12/2024
Date Signed: 10/12/2024 12:48:22 PM

Document Has Been Signed on 10/12/2024 12:48 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
Lookup Error,
, CA
FACILITY NAME:GRANT SERENITY HOMES OF BURBANK, INCFACILITY NUMBER:
198603412
ADMINISTRATOR/
DIRECTOR:		MARTIN ADJIANFACILITY TYPE:
740
ADDRESS:436 N. REESE PLACETELEPHONE:
(818) 425-6797
CITY:BURBANKSTATE: CAZIP CODE:
91506
CAPACITY: 6CENSUS: 5DATE:
10/12/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:26 AM
MET WITH:Maricela Sosa - CaregiverTIME VISIT/
INSPECTION COMPLETED:
01:05 PM
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Licensing Program Analyst (LPA) Mary Flores conducted an unannounced annual visit at the facility using the CARE inspection tool. LPA met with Maricela Sosa and explained the reason for the visit.

Facility is licensed to serve 6 non-ambulatory residents over the age of 60, of which (4) may be bedridden and (2) non-ambulatory, with a hospice waiver for (2). Facility is a single home located in a residential neighborhood an consist of (4) resident rooms, (1) bathroom, a kitchen, a living room, a dining room, a detached garage, a patio, a backyard and front yard.

LPA Flores conducted a tour of the facility and observed the following:
Facility is clean and in good repair indoor and outdoor. The living room has a fireplace which is covered with a metal stand. Facility has sufficient food supplies for at least (2) worth of perishables, and (7) days of non-perishables stored in the kitchen. Cleaning supplies, medication, and sharps were observed locked in kitchen cabinets. Laundry is located in the kitchen. Each resident bedroom has sufficient lighting, the required bedding and furniture. LPA observed bed rails in room #4(BR4) for resident #3(R3) and #4(R4). Bathroom was observed clean, with grab bars, skid mat, and in good repair. Water temperature was tested at 106.4 degrees F., which is within the required 105-120 degrees F. Facility has sound device in each exit door. Backyard has seating furniture under a cover patio. Fire extinguisher was observed and last checked on 10/9/24. All passageways are free of obstructions and debris. There are no large bodies of water in this facility. First aid kit was observed with all required items. Licensing posters were observed posted.

LPA reviewed files and medication for (5) clients and (5) staff files. Administrator certificate was observed for Martin Adjian #6043740740 exp. date: 3/15/25. Staff #1(S1) was observed working at the facility. Per administrator staff began working on 10/10/24, fingerprint clearance was done on 10/7/24.

(CONTINUED ON LIC 809C)
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Mary G Flores
LICENSING EVALUATOR SIGNATURE: DATE: 10/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/12/2024
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
Lookup Error,
, CA
FACILITY NAME: GRANT SERENITY HOMES OF BURBANK, INC
FACILITY NUMBER: 198603412
VISIT DATE: 10/12/2024
NARRATIVE
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Infection control plan and emergency disaster plans were reviewed and are in compliance.

Deficiencies was noted on LIC 809D per Title 22 Regulations.

Exit interview was conducted with Nvard Gevorkian and a copy of this report, LIC 809D, and appeal rights were provided.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Mary G Flores
LICENSING EVALUATOR SIGNATURE:

DATE: 10/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 10/12/2024 12:48 PM - It Cannot Be Edited


Created By: Mary G Flores On 10/12/2024 at 12:30 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
,
, CA

FACILITY NAME: GRANT SERENITY HOMES OF BURBANK, INC
FACILITY NUMBER: 198603412

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/12/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87355(e)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in staff #1(S1) has been working at facility since 10/10/24 and does not have a fingerprint clearance which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/13/2024
Plan of Correction
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Licensee removed S1 from the facility and will wait for S1 to have clearance prior S1 returning to work. Administrator will send a statement to the department to acknowledge that is aware that no staff or volunteer should be present at the facility without a fingerprint clearance per Title 22 Regulations and S1 clearance by POC due date 10/13/24.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Tony Vasallo
LICENSING EVALUATOR NAME:Mary G Flores
LICENSING EVALUATOR SIGNATURE:
DATE: 10/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/12/2024


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 10/12/2024 12:48 PM - It Cannot Be Edited


Created By: Mary G Flores On 10/12/2024 at 12:30 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
,
, CA

FACILITY NAME: GRANT SERENITY HOMES OF BURBANK, INC
FACILITY NUMBER: 198603412

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/12/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87608(a)(3)
87608 Postural Supports
(a) ...assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions. (3) A written order from a physician indicating the need for the postural support shall be maintained in the resident’s record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in 2 out of 5 residents have bed rails in their beds and do not have a physician's order for the bed rails on file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/18/2024
Plan of Correction
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Administrator will obtain a physician's report for half bed rails for R3 and R4 and will submit a copy to the department by POC due date 10/18/24.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Tony Vasallo
LICENSING EVALUATOR NAME:Mary G Flores
LICENSING EVALUATOR SIGNATURE:
DATE: 10/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/12/2024


LIC809 (FAS) - (06/04)
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