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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361880912
Report Date: 05/27/2022
Date Signed: 05/27/2022 01:46:23 PM


Document Has Been Signed on 05/27/2022 01:46 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, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507



FACILITY NAME:A & A CARE AND WELLNESSFACILITY NUMBER:
361880912
ADMINISTRATOR:AKOPYAN, HELENFACILITY TYPE:
740
ADDRESS:16055 SEQUOIA STREETTELEPHONE:
(818) 588-2894
CITY:HESPERIASTATE: CAZIP CODE:
92345
CAPACITY:6CENSUS: 2DATE:
05/27/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Helen Akopyam, Administrator TIME COMPLETED:
02:00 PM
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Licensing Program Analyst (LPA) Javier Prieto arrived to the facility to conduct a case management visit related to the passing of resident #1 (R1). R1 passed away on 05/20/22. Facility reported the incident to the Licensing office within the required time frame. LPA Prieto met with Helen Akopyam, Administrator, and gathered additional documentation. All parties involved were notified of R1s passing and previous medical condition. Additional copies of incident reports and subsequent passing were provided during today's visit. LPA Prieto conducted an exit interview, in which LPA Prieto and administrator Akopyam, signed this report and a copy was left with the facility.
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Javier PrietoTELEPHONE: 951-217-3135
LICENSING EVALUATOR SIGNATURE:
DATE: 05/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/27/2022
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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