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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195850179
Report Date: 10/28/2025
Date Signed: 10/28/2025 05:48:17 PM

Document Has Been Signed on 10/28/2025 05:48 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 N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:YMZ ASSISTED LIVINGFACILITY NUMBER:
195850179
ADMINISTRATOR/
DIRECTOR:		DURGARYAN, REBEKAFACILITY TYPE:
740
ADDRESS:6206 KLUMP AVENUETELEPHONE:
(818) 358-2955
CITY:NORTH HOLLYWOODSTATE: CAZIP CODE:
91606
CAPACITY: 6CENSUS: 6DATE:
10/28/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:03 PM
MET WITH:Hasmik Baklajyan, StaffTIME VISIT/
INSPECTION COMPLETED:
06:00 PM
NARRATIVE
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Licensing Program Analyst(LPA) Christine Yee conducted an unannounced case management visit due to the deficiencies noted on today's visit and during complaint visits conducted by Investigator Veronica Padilla related to complaint #29-AS-20250224100345. LPA Yee was let into the home by Shazada Aknmobha, Staff. Per information provided, she was working part time to cover another staff. The Administrator, Rebeka Durgaryan was contacted and staff indicated that she was on the way to conduct the visit. At 1:36pm, LPA Yee received a telephone call from the Administrator advising that she was sick and would not be participating in today's visit. Hasmik Baklajyan was going to conduct the visit. Ms. Baklajyan arrived at 2:10pm to conduct the visit. The reason for this visit was explained.

The following deficiencies were noted:
  • During the investigation conducted by Veronica Padilla investigator, information was provided that Svetlana Petrosian, staff that works for the licensee at North Care Residential Inc was present at the facility after the fall of Resident #1 on 2/16/25. Per review of Department records, staff was cleared on 4/24/15 and a request for a criminal record transfer to the facility was not processed until 6/19/25.
  • Staff, Shazada Aknmobha, AKA as Sasha, was the only staff present at the facility upon LPA's arrival today. Per Sasha via translation app, she is working part time and is covering for Staff #2. Per review of the Department records, she does not have a criminal record clearance and is not associated to the home.
  • Hospice Initiation and Notifications have not been provided to the Department for residents noted on the


continued on LIC809-C
NAME OF LICENSING PROGRAM MANAGER: Kristin Heffernan
NAME OF LICENSING PROGRAM ANALYST: Christine Yee
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 10/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/28/2025
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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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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Document Has Been Signed on 10/28/2025 05:48 PM - It Cannot Be Edited


Created By: Christine Yee On 10/28/2025 at 02:38 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: YMZ ASSISTED LIVING
FACILITY NUMBER: 195850179

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/28/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/29/2025
Section Cited
CCR
87355(e)(2))

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Criminal Record Clearance: All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: 2) Obtain a California clearance or a criminal record exemption
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The Licensee shall read Title 22, Section 87355 and write a statement that the section was read and understood and a written plan of action is provided that will state how the facility will ensure that all staff present at the facility has received a criminal record clearance and requested a criminal record
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as required by the Department or...This requirement was not met as evidenced by: Shazada A. Zholdoshova, Staff does not have an employee file and no evidence of a criminal record clearance. Per staff, it is her first day covering for Staff #2. Civil penalties were assessed.
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transfer by 10/29/25
Type A
10/29/2025
Section Cited
CCR87355(e)(3)

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Criminal Record Clearance: All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: 3) Request a transfer of a criminal record clearance as specified in Section 87355(c) or
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The Licensee shall read Title 22, Section 87355 and write a statement that the section was read and understood and a written plan of action is provided that will state how the facility will ensure that all staff present at the facility has received a criminal record clearance and requested a criminal record
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This requiement was not met as evidenced by: Svetlana Petrosian, an employee of the licensee at North Care Residential, Inc was observed at the home as staff from the licensees other facilities are used as backup staff and was not associated to the home
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transfer by 10/29/25.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Kristin Heffernan
NAME OF LICENSING PROGRAM MANAGER:
Christine Yee
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/28/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/28/2025


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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: YMZ ASSISTED LIVING
FACILITY NUMBER: 195850179
VISIT DATE: 10/28/2025
NARRATIVE
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Page 2.
  • citation issued on 8/28/24 but not corrected and Resident #1. Per the Administrator, Resident #1 has since been discharged from hospice. Currently there is no one on hospice.


Deficiencies cited under California Code of Regulations, Title 22, Division 6, Chapter 8. CIVIL PENALTIES WERE ASSESSED ON TODAY'S VISIT


Exit interview was conducted, APPEAL RIGHTS were discussed and a copy was provided.
NAME OF LICENSING PROGRAM MANAGER: Kristin Heffernan
NAME OF LICENSING PROGRAM ANALYST: Christine Yee
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2025
LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 10/28/2025 05:48 PM - It Cannot Be Edited


Created By: Christine Yee On 10/28/2025 at 03:52 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: YMZ ASSISTED LIVING
FACILITY NUMBER: 195850179

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/28/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/04/2025
Section Cited
CCR
87632(d)(2)

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Hospice Care Waiver: If the Department grants a hospice care waiver it shall stipulate terms and conditions of the waiver as necessary to ensure the well-being of terminally ill residents and of all other facility residents, which shall include, but not be limited to, the following requirements.
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Licensee will read Title 22 Section 87632 and 87633 and submit a written statement that the sections were read and understood and that the Licensee will comply with all requirements noted in the Section. Licensee will also submit written hospice notification letters containing all
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The licensee shall notify the Department in writing within five working days of the initiation of hospice care services for any terminally ill resident in the facility or within five working days of admitting a resident already receiving hospice care services...... R1 through R4 are on hospice and was not reported
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the required information noted in the Section being cited for resident #1 through resident #4 to the Department by 11/4/25

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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.
Kristin Heffernan
NAME OF LICENSING PROGRAM MANAGER:
Christine Yee
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/28/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/28/2025


LIC809 (FAS) - (06/04)
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