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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603493
Report Date: 12/05/2023
Date Signed: 12/05/2023 12:10:32 PM


Document Has Been Signed on 12/05/2023 12:10 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754



FACILITY NAME:MOON LIGHT BOARDING CARE INCFACILITY NUMBER:
198603493
ADMINISTRATOR:SAKO MANVELYANFACILITY TYPE:
740
ADDRESS:120 N SIERRA BONITA AVETELEPHONE:
(818) 661-7333
CITY:PASADENASTATE: CAZIP CODE:
91106
CAPACITY:6CENSUS: 2DATE:
12/05/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:58 AM
MET WITH:Sako Manvelyan - Administrator TIME COMPLETED:
12:25 PM
NARRATIVE
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Licensing Program Analyst (LPA) Mary Flores conducted an unannounced case management visit during a complaint investigation visit due to deficiency observed at the time of the visit. LPA met with Adrine Adamian caregiver and explained the reason for the visit.

On 12/5/23 LPA Flores was allowed entry to the facility by staff #1(S1), who was providing care and supervision to the residents in care. S1 stated to be working at the facility since 12/2/23. LPA Flores noticed S1 is not associated to the facility. Administrator stated that fingerprint for background clearance had been submitted to the department. LPA contacted the department to check if S1 has a background check and S1 was not found in the system.

Deficiencies are noted on LIC 809D per Title 22 Regulations and Immediate Civil Penalties in the amount of $400.00 are being issued at this time.

Exit interview was conducted with Adrine Adamian and a copy of this report was provided.
SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:
DATE: 12/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/05/2023
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 2


Document Has Been Signed on 12/05/2023 12:10 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754


FACILITY NAME: MOON LIGHT BOARDING CARE INC
FACILITY NUMBER: 198603493

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/05/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/06/2023
Section Cited
CCR
87355(e)(1)

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87355 Criminal Record Clearance: (e) All individuals subject to a criminal record review... shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department... This requirement is not met as evidence by:
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Administrator asked staff to leave and staff will return once background clearance is verify. Administrator will certify in writting to the department that will ensure all staff are cleared before starting to work.
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Based on observation, interviews, and documents review S1 has been working at the facility since 12/2/23 without a background clearance which poses an immediate risk to the health, safety, or personal rights of the persons in care.
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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 VasalloTELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:
DATE: 12/05/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/05/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2