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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603605
Report Date: 02/21/2023
Date Signed: 03/01/2023 03:21:00 PM


Document Has Been Signed on 03/01/2023 03:21 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 03/01/2023 02:52 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

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) Troy Agard conducted an announced visit to the above facility for the purpose of a pre-licensing evaluation. LPA met with Administrator, Varsenik Keshishyan and explained the purpose of the visit. During the inspection LPA toured the inside and outside of the facility and verified the address of the location.

An application was submitted to Community Care Licensing Division (CCLD) on 06/21/2022 for a Change in Ownership (CHOW) for a Continuing Care Residential Community (CCRC) . The total requested capacity is for 175 residents. Facility has a fire clearance dated on 09/22/2022 for 100 ambulatory, 70 non-ambulatory and 5 bedridden residents. There is no memory care unit.

Structure: The facility is located in a residential neighborhood. It is 4-stories in height with a lower level (LL). There is also a skilled nursing facility adjacent to the building. The facility has approximately 140 resident-bedrooms in total. Upon entry on the first floor, the concierge desk is directly to the right. Straight ahead is the main dining room/ lounge area and courtyard. The right hallway is the Assisted Living (AL) wing and the left hallway is the Independent Living (IL) wing. Residents bedrooms run throughout the facility on the 1st, 2nd, 3rd and 4th level. On the LL there is a laundry room, several activity rooms, a gym, movie cinema, beauty salon, private dining space and storage as well as some administrative offices. 1st floor contains several lounge/meeting areas, courtyard, dining, bistro, clinic for medications, kitchen, storage and library. The facility has a parking lot adjacent to the west wing of the building. The courtyard contains a covered patio. LPA did not observe hazards, such as ladders, gardening tools and/or motorized equipment in the front, back and/or side areas of the facility.

Bedrooms: Bedrooms have a chair, nightstand, over-head lighting, dressers and/or closets. The facility can provide furnished or unfurnished rooms. The closets and drawers comply with the requirement of 8 cubic feet of space.


cont 809C
SUPERVISOR'S NAME: Angela J KendrickTELEPHONE: (323) 629-7815
LICENSING EVALUATOR NAME: Troy AgardTELEPHONE: (323) 400-7109
LICENSING EVALUATOR SIGNATURE:
DATE: 02/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/21/2023
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 3


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
FACILITY NAME: ARARAT GARDENS
FACILITY NUMBER: 198603605
VISIT DATE: 02/21/2023
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
26
27
28
29
30
31
32
Office: Facility has several administrative offices throughout the building. Staff records and resident records will be held on site in the Human Resources Administrative Office located in the IL Wing.

Bathrooms: Facility has bathrooms in the common areas. Each bedroom / studio apartment has its own bathroom with a shower. Bathrooms visited were observed to have a working toilet, and wash basin. All stand up showers were observed in working order with secured grab bars. Water temperature tested at 111.4 degrees Fahrenheit

Linens & Hygiene Supplies: Beds have the required linen/supplies which include, pillowcase, mattress pads, fitted sheet, blanket and bedspreads. Adequate supply of linen; sheets, pillowcases, hand towels, bath towels and wash cloths are available to residents. Residents provide their own hygiene supplies. However, the residents have access to hygiene supplies should they need.

Emergency Phone Numbers, Exit Plan & Menu: The telephone, which is a land line, was called by LPA and is operational. Emergency Disaster Plan and "See something, say something, Let Us Know" was observed posted in a foyer located in the AL wing. LPA observed several fully charged fire extinguishers throughout the facility.

Food Service: Dishes, cups and flatware are stored in the kitchen cupboards, inspected and in good repair. Knives, cutlery and other sharp kitchen utensils are stored in a locked cabinet. Food supply was adequately stored in kitchen refrigerator, cabinets and pantry. Facility has a full kitchen that prepares meals.

Smoke Detectors: Facility is equipped with dual smoke and carbon monoxide detectors. Which are hardwired and interconnected throughout the facility. Detectors are connected to notify the fire department in the event of a fire.

Appliances: Stove burners, oven, microwave, washer, and dryer are in working order. There is a large refrigerator in the kitchen. Refrigerator and freezer are at the correct temperature for food storage.



Toxins: Locked/stored in kitchen cabinet.

cont on 809C
SUPERVISOR'S NAME: Angela J KendrickTELEPHONE: (323) 629-7815
LICENSING EVALUATOR NAME: Troy AgardTELEPHONE: (323) 400-7109
LICENSING EVALUATOR SIGNATURE:

DATE: 02/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/21/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
FACILITY NAME: ARARAT GARDENS
FACILITY NUMBER: 198603605
VISIT DATE: 02/21/2023
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
26
27
28
29
30
31
32
Medications, First-Aid Kit & Book: Area for medication storage is in the clinic office. First aid kit was inspected which has at least the following: thermometer, tweezers, scissors, antiseptic, bandages, gauze. First aid and medications are available for staff use but inaccessible to residents.

Clients & Staff Files: Records for staff and residents are stored on site.

Reading Material, Games, Equipment & Materials: The facility has recreational materials for the resident’s use including but not limited to a library, pool table, arts and crafts.

Pool/Jacuzzi & Pets: LPA did not observe a pool or jacuzzi on facility grounds. LPA observed one water fountain fixture that was inoperable. Some pets were observed that belonged to some residents.

Fire clearance: Fire Clearance was approved on 09/22/2022 for 100 ambulatory, 70 non-ambulatory and 5 bedridden residents. Per inspection, all 1st floor rooms are approved for non-ambulatory and bedridden residents. LPA did not observe pad locks or other mechanisms which may be obstructions for safe and quick egress during an emergency on front and back exits. Facility is equipped with a sprinkler system.

Component III: Conducted at the Pre-Licensing visit, on 02/21/2022 at ARARAT GARDENS. Information was provided about how to operate the facility within substantial compliance.

During the pre-licensing inspection, no items were observed which do not comply with applicable laws and regulations; no items require a follow up inspection for verification of correction.

Pre-Licensing is complete, and this facility has no deficiencies.

An exit interview was conducted, and a copy of this report has been furnished to the applicant.

Accordingly, LPA will submit a copy of this facility evaluation report to the Central Applications Bureau (CAB) for review. If the applicant has questions regarding the status of the application, they have been instructed to communicate with the CAB Analyst assigned to the applicant.

SUPERVISOR'S NAME: Angela J KendrickTELEPHONE: (323) 629-7815
LICENSING EVALUATOR NAME: Troy AgardTELEPHONE: (323) 400-7109
LICENSING EVALUATOR SIGNATURE:

DATE: 02/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/21/2023
LIC809 (FAS) - (06/04)
Page: 3 of 3