195850634-5-29-2025-29-AS-CYEE-DH5VZC-20250529165231

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 195850634
Report Date: 05/29/2025
Date Signed: 05/29/2025 04:52:49 PM

Document Has Been Signed on 05/29/2025 04:52 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:	VIKMED INC		FACILITY NUMBER:	195850634
ADMINISTRATOR/ DIRECTOR:	GEVORGYAN,MANE		FACILITY TYPE:	740
ADDRESS:	7459 SYLMAR AVENUE		TELEPHONE:	(747) 257-9540
CITY:	VAN NUYS	STATE: CA	ZIP CODE:	91405
CAPACITY: 6		CENSUS: 0	DATE:	05/29/2025
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:14 AM
MET WITH:	Mane Gevorgyan, Applicant		TIME VISIT/ INSPECTION COMPLETED:	05:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Christine Yee conducted an announced Prelicensing and Component III visit to ensure that the home met Title 22 requirements. The CARE Inspection Tool was used on today's visit. LPA Yee met with Mane Gevorgyan, Applicant. The home is a single storey family home consisting of a living room, dining room, kitchen, 3 bedrooms and 2 full bathrooms. Located in the back of the home is a detached garage. The home is fire cleared for 5 NON-AMBULATORY and 1 BEDRIDDEN residents. Bedroom #1 and Bedroom #2 are approved for bedridden use. The following was observed on today's visit: The living room is furnished with a sofa for 4 residents and a chair, coffee table, a side table, 2 end tables and a television. An additional chair will be added by the applicant. The fireplace was observed with a fire screen. The dining room is furnished with a table, 6 chairs, a desk and a locked filing cabinet. The kitchen is equipped with a stove, refrigerator, dishwasher and a microwave Sufficient dinner plates, salad plates, soup bowl, cups, glasses and utensils for 6 residents were observed. Pots and pans for making meals were observed. Medications will be stored in a locked cupboard, sharp knives stored in a locked drawer and dish soap stored in the locked cabinet beneath the kitchen sink. Sufficient non-perishable foods for a minimum of 7 days were observed on the premises. Perishable

NAME OF LICENSING PROGRAM MANAGER: Kristin Heffernan
NAME OF LICENSING PROGRAM ANALYST: Christine Yee
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/29/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/29/2025

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: VIKMED INC	FACILITY NUMBER: 195850634
	VISIT DATE: 05/29/2025

NARRATIVE

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foods for a minimum of 2 days will be purchased and maintained on the premises prior to accepting the first resident
The only fire extinguisher, purchased on 3/11/25 is mounted in the dining room.
All three bedrooms were observed with 2 twin beds, 2 night stands, 2 lamps, 2 chairs and a built in closet. Bedroom #3 has a 4 drawer dresser. Window dressing were observed on the window and sliding glass doors. An extra curtain panel on the sliding glass door is needed in bedroom #2 for privacy.
All the required bed linens and a pillow was observed on the beds. Extra set of linens and blankets and 13 sets of towels were observed in the cupboard located in the living room.
Hygiene products, cleaning solution, laundry detergent were observed in the locked closet located in the living room.
Little flash rights were observed on the night stands
night light was observed in the hallway.
The laundry closet located by the bedroom #1 was observed with a washer and dryer.
A first aid kit and first aid manual was observed. The first aid kit needs a tweezer.
The hardwired smoke alarms located inside the 3 bedrooms and the only combination smoke/carbon monoxide detector located in the hallway were tested and were operational.
The required postings were observed.
A laptop was observed for resident use
The private bathroom located inside bedroom #2 was observed in a walk-in shower, a toilet, a bath tub, and a single sink. A slip resistant mat and grab bars were observed in the shower and behind the toilet. Grab bar is needed for the bath tub. Water temperature was tested and read 112.1 degrees Fahrenheit
The common bathroom was observed with a walk-in shower, a toilet and a sink. A slip resistant mat and grab bars were observed in the shower and behind the toilet. The water temperature was tested and read 111.1 degrees Fahrenheit.
The back and front yard was toured. The back has a covered patio with table and plenty of chairs for resident activities. Trash cans were observed to be tightly sealed along the garage.

NAME OF LICENSING PROGRAM MANAGER: Kristin Heffernan
NAME OF LICENSING PROGRAM ANALYST: Christine Yee
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/29/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/29/2025

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: VIKMED INC	FACILITY NUMBER: 195850634
	VISIT DATE: 05/29/2025

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The back and front yard was observed to be clean and well maintained.
The garage was toured and had some items stored inside. However, the garage will be primarily used for parking.

The following needs to be corrected prior to licensure:

dressers are needed in bedroom #1 and #2
a tweezer needs to be placed in the first aid kit.
a grab bar needs to added for the bath tub in the private bathroom
an extra curtain panel needs to added in bedroom #2 for privacy

The following will need to be completed upon licensure:

purchase general liability insurance with limits of $1 million per occurrence and $3 million total annual aggregate.
purchase perishable foods for a minimum of 2 days prior to accepting the first resident
create files for residents, staff and volunteers

Component III was conducted with Mane Gevorgyan, Applicant during this visit.

The Applicant will notify LPA Yee once the corrections have been completed.

Exit interview was conducted.

NAME OF LICENSING PROGRAM MANAGER: Kristin Heffernan
NAME OF LICENSING PROGRAM ANALYST: Christine Yee
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/29/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/29/2025

LIC809 (FAS) - (06/04)

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