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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195850549
Report Date: 12/02/2025
Date Signed: 12/02/2025 01:20:37 PM

Document Has Been Signed on 12/02/2025 01:20 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:VALLEY PARADISE BOARDING CAREFACILITY NUMBER:
195850549
ADMINISTRATOR/
DIRECTOR:		NIKOYAN, NAIRAFACILITY TYPE:
740
ADDRESS:12200 HATTERAS STTELEPHONE:
(818) 853-7278
CITY:VALLEY VILLAGESTATE: CAZIP CODE:
91607
CAPACITY: 6CENSUS: 5DATE:
12/02/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:38 AM
MET WITH:Naira Nikoya - LicenseeTIME VISIT/
INSPECTION COMPLETED:
01:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Quoc Huynh arrived at the facility unannounced to conduct a required Annual visit at 9:38AM. The LPA met with the Licensee Naira Nikoyan and explained the reason for the visit. Entrance interview conducted.

Beginning at 9:59AM, the LPA and the Licensee 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 following was observed:

COMMON AREAS: At the time of the visit, two (2) living room and dining room furniture were observed to be in good condition. The entryway had cabinets that contained facility supplies and extra linens. There was a fireplace in the second living room, which was observed to be screened. The second living room also had an office area with a locked cabinet that contained files and additional medications. The facility maintained a comfortable temperature throughout the visit. Required postings were observed near the in the first living room and nightlights were maintained throughout the hallways.


Report Continued on LIC 809-C
NAME OF LICENSING PROGRAM MANAGER: Kristin Heffernan
NAME OF LICENSING PROGRAM ANALYST: Quoc Huynh
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 12/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/02/2025
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 12/02/2025 01:20 PM - It Cannot Be Edited


Created By: Quoc Huynh On 12/02/2025 at 12:41 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: VALLEY PARADISE BOARDING CARE
FACILITY NUMBER: 195850549

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/02/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(a)(11)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) A health screening as specified in Section 87411, Personnel Requirements - General.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above in the Licensee did not have a health screening and TB test which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/16/2025
Plan of Correction
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The Licensee will obtain their Health Screening and TB test results and provide them to CCLD by the POC due date.
Type B
Section Cited
CCR
87465(a)(6)
Incidental Medical and Dental Care Services
(6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility.

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 2 residents medication records were not maintained which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/16/2025
Plan of Correction
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The Licensee will provide CCLD current medication records and submit a statement of understanding to maintain all residents medication records by POC due date.
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:
Quoc Huynh
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 12/02/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/02/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/02/2025 01:20 PM - It Cannot Be Edited


Created By: Quoc Huynh On 12/02/2025 at 12:41 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: VALLEY PARADISE BOARDING CARE
FACILITY NUMBER: 195850549

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/02/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87506(a)
Resident Records
(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff.

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 3 out of 5 resident records were not complete which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/16/2025
Plan of Correction
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The Licensee will obtain a Physician's Report, TB test results, and signatures on consent forms and personal rights and provide all documents to CCLD by POC due date.
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:
Quoc Huynh
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 12/02/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/02/2025


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: VALLEY PARADISE BOARDING CARE
FACILITY NUMBER: 195850549
VISIT DATE: 12/02/2025
NARRATIVE
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KITCHEN: Knives and medications were stored inaccessible in a locked cabinet in addition to a secured medication fridge. Kitchen appliances were clean and in operable condition. The facility had a sufficient supply of perishable and non-perishable food, with an additional pantry in the hallway that contained emergency food and water. Food in the refrigerator and freezer were observed to be properly stored with labels and dates. There was a closet with laundry machines that were operational and contained extra facility supplies.

BEDROOMS/RESTROOMS: There were three (3) total bedrooms, each shared. Bedrooms #1 and #3 had a direct exit to the outside with Bedroom #1 approved for one (1) bedridden resident. Bedrooms were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. There were three (3) total bathrooms in the facility: one (1) private restroom, one (1) shared resident restroom, and one (1) visitor restroom. Restrooms were clean and sanitary and in operating condition with grab bars and non-slip surfaces. The private resident restroom had a locked cabinet that contained facility cleaning supplies. All restrooms were sufficiently stocked with soap and paper products. Hot water was tested and measured between 109.4 degrees F and 109.9 degrees F.

OUTDOOR AREA: The outdoor area was shared with the rear Additional Dwelling Unit (ADU) that was occupied by the Licensee. There was sufficient outdoor furniture with shade. The LPA observed two (2) sheds that had general storage and remained locked. No bodies of water noted, and exits were free of obstructions. The side passageways led to the front yard that had two (2) remote and manual operated driveway gates and a door for everyday use.

RECORDS: Record review began at 10:20AM. Resident records were reviewed for, but not limited to care plans, physician's report, admissions agreement, and consent forms. Resident #1 (R1) did not have a Physician’s Report or TB test completed, and consent forms were not signed. The Licensee stated R1 was having issues with their insurance and did not have a Physician. Resident #2 (R2) did not have a TB test result and consent forms were not signed. Resident #3 (R3) had unsigned consent forms and personal rights.
Report Continued on LIC 808-C
NAME OF LICENSING PROGRAM MANAGER: Kristin Heffernan
NAME OF LICENSING PROGRAM ANALYST: Quoc Huynh
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/02/2025
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: VALLEY PARADISE BOARDING CARE
FACILITY NUMBER: 195850549
VISIT DATE: 12/02/2025
NARRATIVE
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Personnel records were reviewed for, but not limited to health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. The Licensee did not have a health screening or TB test on file and stated they have an appointment to renew the documents.

INFECTION CONTROL/EMERGENCY DISASTER PLAN: During today's visit, LPA reviewed the facility's infection control plan and emergency disaster plan. Both documents were observed to be complete and reviewed annually as required. Emergency disaster drills are conducted quarterly, with the last documented drill on 08/13/2025. Smoke and carbon monoxide detectors were tested at 11:32AM and were operational at the time of the visit. One (1) fire extinguisher was observed in the kitchen and was purchased on 07/17/2025 and fully charged.

MEDICATIONS: Medication review began at 11:34AM. Medications were centrally stored and kept inaccessible in the kitchen and office cabinet. Medications were observed for two (2) residents. Medications were labeled and checked for expiration dates. Medications were not properly documented on the centrally stored medications and destruction record. The Licensee did not maintain a current record for Resident #4 (R4) and requested the Hospice Agency to send the record, which did not include medication start dates. Medications for Resident #5 (R5) did not have accurate start dates.

Pursuant to Title 22 CA Code of Regulations and/or the Health and Safety Code, the following deficiencies were cited (Refer to LIC 809-D).

A Civil Penalty in the amount of $250 was assessed for a repeat violation. The Licensee was informed that continued violation and failure to correct the violation could result in additional civil penalties.

Exit interview conducted. A copy of the appeal rights and report was reviewed and provided.
NAME OF LICENSING PROGRAM MANAGER: Kristin Heffernan
NAME OF LICENSING PROGRAM ANALYST: Quoc Huynh
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/02/2025
LIC809 (FAS) - (06/04)
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