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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603605
Report Date: 09/24/2024
Date Signed: 09/24/2024 04:06:05 PM


Document Has Been Signed on 09/24/2024 04:06 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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364



FACILITY NAME:ARARAT GARDENSFACILITY NUMBER:
198603605
ADMINISTRATOR:KESHISHYAN, VARSENIKFACILITY TYPE:
741
ADDRESS:1230 EAST WINDSOR ROADTELEPHONE:
8182447219
CITY:GLENDALESTATE: CAZIP CODE:
91205
CAPACITY:175CENSUS: 75DATE:
09/24/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Charles Brugh, Interim AdministratorTIME COMPLETED:
04:00 PM
NARRATIVE
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Licensing Program Analysts ( LPA s) Rosaura Valenzuela, Leslie Ngo-Castaneda and Licensing Program Manager Naira Margaryan conducted an unannounced Case Management Visit to the facility and met with the Interim Administrator. LPA informed him that the purpose of this visit was to issue the citations and civil penalties for the deficiencies observed during the Licensing Visit.

The following deficiencies were noted at the time of this Case Management Visit:

Operating out of scope- Upon file review it as noted that facility is Implementing an "Independent Living Plus" program without having obtained prior approval from the Licensing Department

Improper placement of residents- It was observed that non-ambulatory residents are being housed on the second and third floors.

Fire clearance upon review of facility file LPAs and LPM received the following information; facility does not have approved fire clearance for non-ambulatory residents to reside on the second floor.

No updated physician's report-Upon file review, it was noted that residents physician's reports and needs and services plan are not being updated as needed.

Per the California Code of Regulations (CCR), Title 22, Division 6, Chapter 8, the following deficiencies were observed and cited (Refer to LIC 809-D).
Exit interview conducted and a copy of the report was issued.
SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Rosaura ValenzuelaTELEPHONE: 818-596-4334
LICENSING EVALUATOR SIGNATURE:
DATE: 09/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/24/2024
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


Document Has Been Signed on 09/24/2024 04:06 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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364


FACILITY NAME: ARARAT GARDENS
FACILITY NUMBER: 198603605

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/24/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/25/2024
Section Cited
CCR
87202

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87202-Fire Clearance -All facilities shall maintain a fire clearance approved by the city fire department..Prior to accepting or retaining.. non-ambulatory persons, the licensee shall notify the licensing agecy and obtain an appropiate fire clearance...
This requirement was not met as evidenced
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The Licensee will request additional non-ambulatory file clearance for the second and third floor residents by submitting LIC 200 and facility sketch within 24 hours.
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by:
Upon review of facility file LPAs and LPM received the following information; facility does not have approved fire clearance for non-ambulatory residents to reside on the second floor. This poses an immediate health and safety risk to residents in care.
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Type B
10/15/2024
Section Cited
CCR87294(b)

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87204(b)-Limitations-Capacity and Ambulatory Status-Resident rooms approved for 24 hour care of ambulatory residents only shall not accommodate nonambulatory residents. Resdients whose conditon becomes nonambulatory shall not remain in rooms restricted to ambulatory
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in addition to submission of LIC200 and facility sketch, Licensee will provide a written statement how they will ensure to met the limitations of capacity versus ambulatory status.
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residents,
This requirement was not met as evidenced by:
It was observed that non-ambulatory residents were residing in ambulatory rooms.This poses a potential health and safety risk to residents 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: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Rosaura ValenzuelaTELEPHONE: 818-596-4334
LICENSING EVALUATOR SIGNATURE:
DATE: 09/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/24/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 09/24/2024 04:06 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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364


FACILITY NAME: ARARAT GARDENS
FACILITY NUMBER: 198603605

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/24/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/08/2024
Section Cited
CCR
87208(a)

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87208(a)-Plan of Operation-Each facility shall have and maintain a current, written definitive plan of operation. The plan and related mateials shall be on file in the facility and shall be submitted to licensing...Any significant changes in the plan of operation ...shall be submitted to licensing
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The Licensee shall submit in writing to Licensig an updated plan of operation by 10/08/24.
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for approval. This requirement was not met as evidence by:
Upon file review it as noted that facility is Implementing an"Independent Living Plus" program without having obtained prior approval from the Licensing Department This poses a potential health and safety risk to residents in care.
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Type B
10/08/2024
Section Cited
CCR87463(a)

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87463(a) Reappraisals-The pre-admission appraisal shall be submitted in writing as frequently as necessary to note significant changes and to keep the appraisal accurate.,,

This requirement was not met as evidenced by:
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The Licensee shall update all the medical records and needs and services plans of all residents in care by 10/08/2024.
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it was noted that residents physician's reports and needs and services plan are not being updated as needed.

This poses a potential health and safety risk to residents 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: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Rosaura ValenzuelaTELEPHONE: 818-596-4334
LICENSING EVALUATOR SIGNATURE:
DATE: 09/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/24/2024
LIC809 (FAS) - (06/04)
Page: 3 of 3