195850734-5-29-2026-29-AS-ABAN-DUJQ9E-20260529115814

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 195850734
Report Date: 05/29/2026
Date Signed: 05/29/2026 11:58:47 AM

Document Has Been Signed on 05/29/2026 11:58 AM - 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:	ASSISTED COMFORT HOME #2		FACILITY NUMBER:	195850734
ADMINISTRATOR/ DIRECTOR:	KEVLIYAN, MARIAM		FACILITY TYPE:	740
ADDRESS:	23730 KILLION ST		TELEPHONE:	(818) 800-9970
CITY:	WOODLAND HILLS	STATE: CA	ZIP CODE:	91367
CAPACITY: 6		CENSUS: 2	DATE:	05/29/2026
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	10:00 AM
MET WITH:	Mariam Kevliyan		TIME VISIT/ INSPECTION COMPLETED:	12:10 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) Angela Barutyan conducted an announced pre-licensing visit to the facility noted above at 10:00AM. LPA met with Administrator/Applicant Mariam “Maya” Kevliyan. The applicants have obtained fire clearance for a total capacity of six (6) residents; five (5) non-ambulatory and one (1) bedridden. LPA inspected facility for Fire Safety, Personal Accommodations and Services, and Food Service. The facility is one story. The facility has five (5) bedrooms total; two (2) are private resident-use, two (2) are shared resident-use, and one (1) is for staff-use. Bedrooms #1 and #4 are cleared for bedridden use and Bedrooms #2 and #3 are cleared for non-ambulatory use. The combination smoke alarm/carbon monoxide detectors were tested and functioned properly. LPA observed fire extinguisher to be fully charged and last serviced on 03/27/2026. LPA toured the kitchen area at approximately 10:04AM. The hot water temperature was measured in the kitchen sink, and it measured at 112.5 degrees Fahrenheit. Appliances and all equipment appear to be clean and in good repair. The kitchen has a sufficient supply of plates, cups, cookware, and utensils. Kitchen knives and sharps are locked in a cabinet drawer. LPA observed the locked garage by the kitchen which contained a washer and dryer, cleaning supplies, toxins, detergents, disinfectants, locked medication fridge, and emergency food and water supply. Report Continued on LIC 809C.

NAME OF LICENSING PROGRAM MANAGER: Kristin Heffernan
NAME OF LICENSING PROGRAM ANALYST: Angela Barutyan
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/29/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/29/2026

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: ASSISTED COMFORT HOME #2	FACILITY NUMBER: 195850734
	VISIT DATE: 05/29/2026

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Resident bedrooms are equipped with clean mattresses, pillows, and bedding. Bedrooms have sufficient lighting. There is a sufficient supply of linens, including blankets, bath towels, and wash cloths. The facility has three (3) bathrooms total. Bedroom #4 has an attached bathroom, there is one (1) bathroom located in the hallway for staff and residents, and Bedrooms #2 and #3 have a shared Jack-and-Jill bathroom. Bathrooms contained appropriate slip-resistant surfaces and grab bars. Hot water temperature was measured in all bathrooms, and they measured between 105.3-111.4 degrees F, which is within the required range.

The living room and dining room are clean and properly furnished. All window screens and coverings are in good repair. Fireplaces in living room and dining room were adequately screened. LPA observed enough seating for six (6) residents at the same time at the dining room table. A working telephone is present. There are activity supplies in the living room. LPA observed additional linens, bedding, and towels in the hallway closets Medications and First Aid Kit were stored locked and inaccessible in cabinet in the dining room. First Aid Kit was observed to have bandages, thermometer, scissors, tweezers, and a current first aid manual. Facility records will be maintained in the dining room cabinet. Cameras were observed inside and outside, with no audio component. Auditory exit alarms in bedrooms and common areas were functioning properly.

There will be no firearms/ammunition stored on the property. The facility has required postings, including Emergency Exit Plan, Licensing Complaint Poster, Resident Personal Rights, and Theft and Loss Policy.
The exterior passageways were free of obstructions. LPA observed the backyard, which has a covered outdoor area with a table and chairs for resident use. The in-ground pool was fenced and gated.

Physical plant is consistent with the submitted facility sketch/floor plan.
Comp III conducted with Administrator/Applicant.

Pre-Licensing is complete and this facility has no deficiencies.

This report will be sent to the Centralized Application Bureau (CAB). You will be notified by the CAB Analyst when your license has been approved. You are not allowed to begin operating until you have been notified that your license has been approved by the CAB Analyst. Failure to comply could affect approval of your license.

Exit interview conducted. The report was reviewed, and a copy was provided.

NAME OF LICENSING PROGRAM MANAGER: Kristin Heffernan
NAME OF LICENSING PROGRAM ANALYST: Angela Barutyan
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/29/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/29/2026

LIC809 (FAS) - (06/04)

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