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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195850391
Report Date: 12/17/2024
Date Signed: 12/17/2024 04:25:54 PM

Document Has Been Signed on 12/17/2024 04:25 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:VAN NUYS SENIOR LIVING, INC.FACILITY NUMBER:
195850391
ADMINISTRATOR/
DIRECTOR:		AYVAZYAN, SARGISFACILITY TYPE:
740
ADDRESS:14822 COHASSET STREETTELEPHONE:
(747) 253-0007
CITY:VAN NUYSSTATE: CAZIP CODE:
91405
CAPACITY: 6CENSUS: 6DATE:
12/17/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:SARGIS AYVAZYAN- Administrator TIME VISIT/
INSPECTION COMPLETED:
04:40 PM
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Licensing Program Analysts (LPA) Erica Mosley arrived at the facility unannounced to conduct a required annual visit and entered the facility at 1:00 p.m. Upon arrival, LPA Mosley was greeted by staff and called the Administrator to inform them of the visit. The Administrator arrived shortly thereafter. The LPA met with SARGIS AYVAZYAN – Administrator and explained the reason for the visit. The LPA toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations.

The facility is a single-story family home consisting of a living room, dining room, kitchen, 4 bedrooms of which one is used for live-in staff, an office, a laundry room, 2 full bathrooms and an attached garage. The facility is fire cleared for 3 NON-AMBULATORY and 3 BEDRIDDEN residents. Bedrooms #1, #2 and #4 are designated for bedridden residents. The home is also equipped with a sprinkler system.

KITCHEN: The LPA inspected the kitchen/food service area at 1:35 p.m. Knives and sharps were observed in a locked drawer. Kitchen appliances were in operable condition. Chemical storage is kept locked under the sink. The facility has a sufficient supply of two (2) day perishable and seven (7) day non-perishable food. Refrigerator and food pantry were checked for proper labels and expiration dates. The kitchen faucet was measured for hot water temperature, and it measured 117.1 degrees Fahrenheit at 1:42 p.m.

(PAGE 1) Report Continued on LIC 809C PAGE 2...

SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Erica Mosley
LICENSING EVALUATOR SIGNATURE: DATE: 12/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/17/2024
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
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: VAN NUYS SENIOR LIVING, INC.
FACILITY NUMBER: 195850391
VISIT DATE: 12/17/2024
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(PAGE 2) Report Continued from LIC 809 PAGE 1...
COMMON AREAS: At the time of the visit, furniture in the common areas was observed to be in good condition. The facility maintained a comfortable temperature. At 3:31 p.m., hardwire combination of smoke / carbon monoxide detector were tested and operational at the time of the visit. The fire extinguisher was observed and fully charged on 07/11/2024. The LPA observed required postings throughout the common space. The last emergency disaster drill took place on 10/24/2024. Activities were observed in the common areas. The fireplace was adequately screened at the time of the visit. Adjacent to the kitchen is a laundry room, with a washer and dryer.
RESTROOMS: There are two (2) restrooms designated for resident use. Resident restrooms were observed to be equipped with nonskid surfaces. Grab bars were observed in both bathrooms. The restrooms were sufficiently stocked with supplies and paper towels. The water temperature was measured in both resident restrooms between 117.0-117.1 degrees Fahrenheit all within the required range.
BEDROOMS: There are four (4) total bedrooms in the facility. Three (3) bedrooms are designated as shared, double occupancy resident rooms and one (1) staff room. The staff room is kept locked. All resident rooms were observed to be furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting.
GARAGE/BACKYARD: The garage is maintained locked at all times. LPA observed an adequate amount of emergency food and water. Cleaning supplies are kept in the garage locked and inaccessible to residents in care. The backyard has a covered patio area with patio furniture including a table and chairs for resident use. All passageways were observed to be clear. There were no bodies of water noted at the time of the visit. Laundry detergent was observed in a locked cabinet in the garage.
MEDICATIONS: Medications review began at approximately 3:18 p.m. The medications are in a locked cabinet adjacent to the living room. Medications for three (3) residents were reviewed. Medications reviewed were found to be self administered as prescribed and documented on the centrally stored medication and destruction records. No errors observed at the time of the visit.
Report Continued on LIC 809C PAGE 3...
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Erica Mosley
LICENSING EVALUATOR SIGNATURE:

DATE: 12/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3
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: VAN NUYS SENIOR LIVING, INC.
FACILITY NUMBER: 195850391
VISIT DATE: 12/17/2024
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(PAGE 3) Report Continued from LIC 809C PAGE 2...

RECORDS: Record review began at approx. 1:48 pm. Resident Records: Six (6) Resident files were reviewed for, but not limited to, the following: signed admission agreements, current medical assessments with TB results, LIC627(c) Consent for Treatment form, and current needs and services plan. Three (3) Personnel files including the Administrator’s file were reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All records were in order.

INTERVIEWS: Interviews began at approx. 3:40pm. Two (2) staff interviews were conducted. Interviews revealed that staff are knowledgeable in resident rights, different forms of abuse and reporting procedures. Three (3) resident interviews were conducted during the inspection. No concerns noted at the time of the visit.

No deficiencies were cited during today’s inspection. Exit interview conducted. A copy of the report was provided.

SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Erica Mosley
LICENSING EVALUATOR SIGNATURE:

DATE: 12/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2024
LIC809 (FAS) - (06/04)
Page: 3 of 3