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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603652
Report Date: 09/14/2023
Date Signed: 09/21/2023 12:05:22 PM

Document Has Been Signed on 09/21/2023 12:05 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:1 DUARTE CAREFACILITY NUMBER:
198603652
ADMINISTRATOR:GASARDZHYAN, OVSEPFACILITY TYPE:
740
ADDRESS:2436 EL TORO ROADTELEPHONE:
(323) 697-4619
CITY:DUARTESTATE: CAZIP CODE:
91010
CAPACITY: 4CENSUS: 0DATE:
09/14/2023
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Applicant-Ovsep Gasardzhyan TIME COMPLETED:
12:35 PM
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Licensing Program Analyst (LPA) Ashley Calderon conducted an announced pre-licensed visit and met with Applicant Ovsep Gasardzhyan for the purpose of conducting a Pre-Licensing Inspection / Component III visit.

The facility has an approved fire clearance dated 8/3/23 to be licensed to serve four (4) non-ambulatory elderly residents. The facility is a single-story home: 4 bedrooms, 2 bathrooms, living room, and kitchen. The backyard has two locked tool sheds used for storage, facility located in the City of Duarte, CA.

Detached garage was converted to an ADU, permit dated 9/16/2022, permit was provided to LPA. ADU has a separate address 633 Camino Real. Applicant will send updated sketch to CCIB. Residents and Staff will not have access to the ADU. Applicant will place fencing around ADU for inaccessibility from the backyard of the licensed facility and Applicant will contact licensing when construction is done.

The physical plant was toured inside and out alongside Ovsep Gasardzhyan. Pre-Licensed Inspection Tool was used.


The following was observed/inspected:

· There is a locked storage area that is located for medication in the hallway cabinet.

· Cleaning supplies are kept separate from food and locked and located in the side closet outside the kitchen door.

· Facility walls, ceilings, floors, window screens and areas around the facility are clean and in good repair.

· Fire extinguishers, carbon monoxides and smoke detectors are operating properly.

· Doors and passageways are free of obstruction.

· There are no pools/bodies of water at this facility.

· Facility does not have firearms on premises.

(Continued on 809-C)

SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Ashley Calderon
LICENSING EVALUATOR SIGNATURE: DATE: 09/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/14/2023
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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: 1 DUARTE CARE
FACILITY NUMBER: 198603652
VISIT DATE: 09/14/2023
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·There is an emergency exiting plan with emergency phone numbers posted.

· Facility has a current disaster plan maintained at the facility.

· Operating telephone is on the premises and will be available to clients, facility number: 626-256-6146.

· First-aid supplies / manual are maintained and readily available.

· Refrigerator and freezer were observed and are maintained at the correct temperatures.

· Food storage and preparation are clean and appropriate for food preparation.

· Hot water temperature was tested and is within the required range of 105-120 degrees F.

During today's visit Component III was completed with Applicant Ovsep Gasardzhyan.

Applicant stated submitting Hospice Wavier for (4) to CCIB, LPA and Applicant will follow up with CCIB.

Applicant passed the Pre-licensing Visit and Component III.

An exit interview was conducted, and a copy of this report will be sent to Applicant Ovsep Gasardzhyan via email due to LPA, printer issues. 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 their application.

SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Ashley Calderon
LICENSING EVALUATOR SIGNATURE:

DATE: 09/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2023
LIC809 (FAS) - (06/04)
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