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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603601
Report Date: 10/12/2026
Date Signed: 10/12/2026 04:42:20 PM

Document Has Been Signed on 10/12/2026 04:42 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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:GRANT SERENITY OF DEL MAR INC.FACILITY NUMBER:
198603601
ADMINISTRATOR/
DIRECTOR:		NATALIIA ARPENTIEVAFACILITY TYPE:
740
ADDRESS:3049 E. DEL MAR BLVDTELEPHONE:
(818) 425-6797
CITY:PASADENASTATE: CAZIP CODE:
91107
CAPACITY: 6CENSUS: 5DATE:
10/12/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:20 PM
MET WITH:Licensee Nvard GevorkianTIME VISIT/
INSPECTION COMPLETED:
04:50 PM
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Licensing Program Analyst (LPA) Blanca Gonzalez conducted an unannounced required annual visit. LPA was greeted by staff and reason for the visit was explained. Licensee Nvard Gevorkian arrived shortly after.

The facility is licensed to serve six (6) non-ambulatory residents age range 60 and over, of which one (1) may be bedridden in room #1 only. Hospice waiver in place for six (6).

The facility is a single-story home located in Pasadena. The home consists of four (4) resident bedrooms, two (2) resident bathrooms, a living room, a dining area, a kitchen, a laundry area, a front yard, and a backyard and detached garage.

LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:

The front and backyard are well maintained. There is a covered patio in the back yard with sufficient seating. Passageways and exits are free of obstruction.

Bathrooms were observed to be clean and free of odors. The water temperature was tested in the bathrooms and measured 115.1°F and 115.7°F which is within the required 105° F – 120° F. LPA observed grab bars and non-skid mats in showers. Resident bedrooms were observed to contain the required furniture which includes, for each resident, a bed, a chair, night stand, a lamp or lights sufficient for reading. Bed linens were clean and in good repair. There is closet space for clothing and other belongings.

continued on LIC809C

Wei Siew Ho
Blanca Gonzalez
DATE: 10/12/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/12/2026
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
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: GRANT SERENITY OF DEL MAR INC.
FACILITY NUMBER: 198603601
VISIT DATE: 10/12/2026
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A carbon monoxide detector is located in the hall, was tested and is operable. Smoke detectors were observed in the bedrooms, living room and hallway, were tested and are operable. There is a fire extinguisher in the laundry area, near the kitchen, last serviced 09/10/2026. Last emergency drill was conducted 07/13/2026.

Kitchen area was observed to be clean and free of litter, rodents, vermin and insects. Appliances are clean and were operating at the time of the visit. Sharps are locked and are inaccessible to residents. Cleaning supplies and disinfectants are locked and are inaccessible to the residents. Sufficient supply of 2 days perishable and 7 days non-perishable foods were observed. Dining area and living room were observed to be clean and free of obstructions and have sufficient seating for residents in care.

Medications are centrally stored in a locked cabinet in the dining area.

LPA reviewed five (5) resident files. Files were observed to contain required documentation consisting of Admission Agreement, Medical Assessment with TB clearance and ambulatory status, resident appraisal, needs and service plan, consent forms, and personal rights.

LPA reviewed four (4) staff files. Staff files were observed to contain required documentation including personnel record, fingerprint clearance, health screening with TB clearance, CPR/First aid certificate and continued education in-service trainings.

Per California Code of Regulations, Title 22, and California Health and Safety Code, no observed were during today’s visit.

Exit interview held and a copy of this report was provided to Ani Karapetyan.

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Blanca Gonzalez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/12/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2026
LIC809 (FAS) - (06/04)
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