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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195850501
Report Date: 07/17/2025
Date Signed: 07/17/2025 08:07:28 PM

Document Has Been Signed on 07/17/2025 08:07 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:BELLAIRE SENIOR CAREFACILITY NUMBER:
195850501
ADMINISTRATOR/
DIRECTOR:		GEVORGYAN, EVAFACILITY TYPE:
740
ADDRESS:6523 BELLAIRE AVENUETELEPHONE:
(818) 987-1115
CITY:NORTH HOLLYWOODSTATE: CAZIP CODE:
91606
CAPACITY: 6CENSUS: 5DATE:
07/17/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:41 AM
MET WITH:Erna Gevorgyan, AdministratorTIME VISIT/
INSPECTION COMPLETED:
08:15 PM
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Licensing Program Analyst (LPA) Christine Yee conducted an unannounced required Annual Inspection and used the CARE Inspection Tool on today's visit. LPA Yee met with Erna Gevorgyan, Administrator and the reason for today's visit was provided. Also present during the visit were Staff, David Abramyan and Ramila Sultanova.

The facility is a single storey family home consisting of a living room, dining room, kitchen, 3 bedrooms, 2 full bathrooms and a car port. The facility is fire cleared for 5 non-ambulatory and 1 bedridden resident. Bedroom #1(back) is designated for bedridden use for the one resident. Located in the back of the facility is an ADU with it's own address of 6521 Bellaire Avenue that is rented out.

On today's visit, all 12 domains of the CARE Inspection Tool was reviewed, 5 Resident files and 5 staff files were reviewed and a tour of the physical plant was conducted.

The following were observed on today's visit:
  • the living room and dining room are furnished with the appropriate furniture and sitting for 6 residents
  • the kitchen is equipped with a refrigerator, dishwasher, toaster oven, microwave and coffee maker.
  • sufficient plates, cups and bowls were observed.
  • knives were observed in a locked kitchen drawer.
  • cleaning solutions, dish detergent and laundry detergent are locked in a cabinet under the kitchen sink.
  • Medications are locked in a cabinet in the kitchen, including the First Aid kit and first aid manual
NAME OF LICENSING PROGRAM MANAGER: Kristin Heffernan
NAME OF LICENSING PROGRAM ANALYST: Christine Yee
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/17/2025
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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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: BELLAIRE SENIOR CARE
FACILITY NUMBER: 195850501
VISIT DATE: 07/17/2025
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  • all three bedrooms were observed with 2 hospital beds each, 2 chairs, 2 night stands, 2 lamps and a built in closet. Full bed rails were observed on the beds located in bedroom #1 and bedroom #3. Residents are receiving hospice services.
  • the hospitals beds were observed with a mattress cover, a fitted sheet and a light blanket. Flat sheets, blankets and comforters were observed in the residents dresser drawers and closet.
  • Located inside bedroom #1 is a private bathroom equipped with a walk in shower, a shower chair, grab bars and slip resistant mat, a toilet and a single sink. Hygiene products are stored in a locked dresser drawer placed in the bathroom. Water temperature was tested and read 118.8 degrees Fahrenheit.
  • The common bathroom is equipped with a walk in shower, toilet and a single sink. A slip resistant mat and grab bars in the shower and the toilet were observed. The water temperature was tested and initially read 120.2 and was re-tested at 7:23pm and it read 119.1 degrees Fahrenheit.
  • 2 fire extinguishers were observed in the kitchen.
  • The first aid kit was reviewed and contained gauze, band aids, the required tweezer, scissors and thermometer.
  • the air conditioner was operational
  • the hardwired combination smoke/carbon monoxide detectors located inside the 3 resident bedrooms, the hallway and in the dining room were tested and were operational.
  • The auditory device on the 3 outside exiting doors-bedroom #1, kitchen and front door -were tested and were operational
  • The backyard was observed with a table and six chairs under a covered patio. Also located under the covered patio was a washer and dryer.
  • The trash cans were observed out on the curb for trash pick up.

Deficiencies were cited under California Code of Regulations, Title 22, Division 6, Chapter 8

Exit interview was conducted, Appeals Rights were discussed and a copy was given.
NAME OF LICENSING PROGRAM MANAGER: Kristin Heffernan
NAME OF LICENSING PROGRAM ANALYST: Christine Yee
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/17/2025 08:07 PM - It Cannot Be Edited


Created By: Christine Yee On 07/17/2025 at 07:41 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: BELLAIRE SENIOR CARE
FACILITY NUMBER: 195850501

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/17/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(d)
Incidental Medical and Dental Care Services
(d) If the resident is unable to determine his/her own need for a prescription or nonprescription PRN medication, and is unable to communicate his/her symptoms clearly, facility staff designated by the licensee, shall be permitted to assist the resident with self-administration, provided all of the following requirements are met:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 2 out of 5 resident files reviewed revealed that Resident #1 takes Oxycodone HCL 5mg and Methocarbmol 500mg and Resident #2 takes Acetaminophen 500mg and did not have completed PRN Authorization Letters on file for their prn medications which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/24/2025
Plan of Correction
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The Licensee will ensure that all residents who take PRN medications obtain a PRN Authorization Letter completed by their physician and that it is maintained in their file. Licensee will contact the prescribing physician and obtain a completed PRN Authorization Letter for Resident #1 and Resident #2s PRN medications. Provide evidence that the PRN letters have been obtained by 7/24/25.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: 07/17/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/17/2025


LIC809 (FAS) - (06/04)
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