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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608579
Report Date: 04/27/2026
Date Signed: 04/27/2026 01:30:44 PM

Document Has Been Signed on 04/27/2026 01:30 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 S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:NO PLACE LIKE HOME FOR GOLDEN AGESFACILITY NUMBER:
197608579
ADMINISTRATOR/
DIRECTOR:		EMMA TOPADZHIKYANFACILITY TYPE:
740
ADDRESS:1459 WESTERN AVENUETELEPHONE:
(818) 245-6799
CITY:GLENDALESTATE: CAZIP CODE:
91201
CAPACITY: 6CENSUS: 5DATE:
04/27/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:20 AM
MET WITH:Emma Topadzuikyan, AdministratorTIME VISIT/
INSPECTION COMPLETED:
01:45 PM
NARRATIVE
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On 04/27/26, at 09:20am, Licensing Program Analyst (LPA) Gina Saucedo arrived at the facility to conduct an unannounced, annual visit. LPA met with, unauthorized caregivers, Rebecca Leis and Janet Faraon. and were advised of the visit. Another caregiver arrived about an hour later named Alla Abajian. Emma Topadzuikyan, the administrator arrived about an hour and 1/2 later.

LPA asked for the census, resident, and staff files.

There is one (1) entrance being utilized at the facility. The facility has a total of six (06) resident bedrooms and three (03) bathrooms.



Outside/Backyard: The facility has outdoor furniture with a covered shaded area for residents and visitors. The facility has a swimming pool/body of water that does not have any water. There is detached garage used as storage. There is also one (1) washer and dryer.

Kitchen area: Kitchen is sufficiently stocked with at least seven (07) days perishable and seven (07) days non-perishable food. There is one (1) refrigerator with frozen foods wrapped and stored appropriately. Food storage and preparation areas are clean and inaccessible to pests. Knives and sharps are observed and were not locked and were accessible to residents.


LIC 809C continued
NAME OF LICENSING PROGRAM MANAGER: Troy Agard
NAME OF LICENSING PROGRAM ANALYST: Gina Saucedo
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/27/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/27/2026
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 9
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 S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: NO PLACE LIKE HOME FOR GOLDEN AGES
FACILITY NUMBER: 197608579
VISIT DATE: 04/27/2026
NARRATIVE
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No firearms observed or will be maintained on the premises. The smoke alarm and carbon monoxide detector were tested and operational. They are hardwired.

Living Room and Dining Room: The living and dining room are neat and clean. The facility maintains a comfortable temperature at 71°F. The smoke and carbon monoxide detectors are hardwired, interconnected and observed to be operational. The medication is locked and inaccessible to the residents in a black cabinet. Fire extinguisher is fully charged and last purchased 04/2025. There is a fire place that is enclosed with a fence.



Bedrooms: Facility has six (6) bedrooms and were toured. The bedrooms are fully furnished with proper lighting and bedding. There are six (6) bedrooms. One (1) is currently vacant and the other five (5) are single, occupied.

Bathrooms: There are three (3) full bathrooms. The bathrooms contained a trash can with tight-fitting lid. Two (2) of the bathrooms are in the hallways. One (1) bathroom is private. The hot waters were tested and measured around 113.5 within regulations.

Administrative: The administrative Certification is current and expires 11/10/2027. The facility did not have insurance at the time of the visit. There were Rights of Resident Council and Personal Rights and the Ombudsman sign against the wall of the facility. The facility has cameras in common areas.

Staff/Client Files: There were no staff files to review at the above facility. There were five (5) resident files that were reviewed. One (1) resident file was missing Physician's Report. Two (2) residents were missing resident appraisals, One (1) resident was Admission Agreement and Pre-placement Appraisal. The last fire drill was on 02/2026.

An exit interview was conducted, several citation(s) were issued, appeal rights were provided and a copy of this report was given to the administrator.

NAME OF LICENSING PROGRAM MANAGER: Troy Agard
NAME OF LICENSING PROGRAM ANALYST: Gina Saucedo
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/27/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/27/2026
LIC809 (FAS) - (06/04)
Page: 3 of 9
Document Has Been Signed on 04/27/2026 01:30 PM - It Cannot Be Edited


Created By: Gina Saucedo On 04/27/2026 at 11:40 AM
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., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: NO PLACE LIKE HOME FOR GOLDEN AGES
FACILITY NUMBER: 197608579

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/27/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space and Access
(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on the observation, the licensee did not comply with the section cited above in one out of one cabinet of knives were not locked and accessible to residents which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/28/2026
Plan of Correction
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The administrator/Licensee will make sure that the cabinets that have knives are kept locked and inaccessible to all residents and visitors.
Type A
Section Cited
CCR
87412(a)(13)
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: (13) For employees that are required to be fingerprinted pursuant to Section 87355, Criminal Record Clearance:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on the record review the licensee did not comply with the section cited above in two (2) out of three (3) staff did not have their fingerprint/Criminal Clearance at the facility which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/28/2026
Plan of Correction
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The administrator/Licensee will make sure that all staff working at the facility are fingerprinted have criminal clearance.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Troy Agard
NAME OF LICENSING PROGRAM MANAGER:
Gina Saucedo
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/27/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/27/2026


LIC809 (FAS) - (06/04)
Page: 4 of 9
Document Has Been Signed on 04/27/2026 01:30 PM - It Cannot Be Edited


Created By: Gina Saucedo On 04/27/2026 at 11:40 AM
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., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: NO PLACE LIKE HOME FOR GOLDEN AGES
FACILITY NUMBER: 197608579

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/27/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87615(a)
Prohibited Health Conditions
(a) Persons who require health services for or have a health condition including, but not limited to, those specified below shall not be admitted or retained in a residential care facility for the elderly:

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on the observation the licensee did not comply with the section cited above in one (1) out of five (5) residents had a feeding tube which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/28/2026
Plan of Correction
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The administrator/Licensee will make sure that the resident that has the feeding tube is returned to a hospital or/and the feeding tube is removed per doctor's orders.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Troy Agard
NAME OF LICENSING PROGRAM MANAGER:
Gina Saucedo
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/27/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/27/2026


LIC809 (FAS) - (06/04)
Page: 5 of 9
Document Has Been Signed on 04/27/2026 01:30 PM - It Cannot Be Edited


Created By: Gina Saucedo On 04/27/2026 at 11:40 AM
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., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: NO PLACE LIKE HOME FOR GOLDEN AGES
FACILITY NUMBER: 197608579

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/27/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.605
Other Provisions
On and after July 1, 2015, all residential care facilities for the elderly, except those facilities that are an integral part of a continuing care retirement community, shall maintain liability insurance covering injury to residents and guests in the amount of at least one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate, caused by the negligent acts or omissions to act of, or neglect by, the licensee or its employees.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on the record review the licensee did not comply with the section cited above in there was no liability insurance which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/11/2026
Plan of Correction
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The administrator/Licensee will make sure that the liability insurance is sent to the Woodland Hills Regional Office/Community Care Licensing Department
Type B
Section Cited
HSC
1569.618(c)(3)
Other Provisions
(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on the record review the licensee did not comply with the section cited above in three (3) out of three (3) staff did not have CPR/First Aid which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/11/2026
Plan of Correction
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The administrator/Licensee will make sure that the all staff receive CPR/Firstaid and put it in their file.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Troy Agard
NAME OF LICENSING PROGRAM MANAGER:
Gina Saucedo
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/27/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/27/2026


LIC809 (FAS) - (06/04)
Page: 6 of 9
Document Has Been Signed on 04/27/2026 01:30 PM - It Cannot Be Edited


Created By: Gina Saucedo On 04/27/2026 at 11:40 AM
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., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: NO PLACE LIKE HOME FOR GOLDEN AGES
FACILITY NUMBER: 197608579

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/27/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(f)
Personnel Records
(f) All personnel records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. Records may be removed if necessary for copying. Removal of records shall be subject to the following requirements:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on the record review the licensee did not comply with the section cited above in there was no staff files to review at the above facility for stafff that were working which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/11/2026
Plan of Correction
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2
3
4
The administrator/Licensee will make sure that the all staff files are kept at the facility for inspection/audit for the licensing agency/department to review.
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
1
2
3
4
Based on the record review the licensee did not comply with the section cited above in there was no health screening for any of the staff that were present at the facility which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/11/2026
Plan of Correction
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2
3
4
The administrator/Licensee will make sure that the all staff files have health screening for each staff present at the facility.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Troy Agard
NAME OF LICENSING PROGRAM MANAGER:
Gina Saucedo
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/27/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/27/2026


LIC809 (FAS) - (06/04)
Page: 7 of 9
Document Has Been Signed on 04/27/2026 01:30 PM - It Cannot Be Edited


Created By: Gina Saucedo On 04/27/2026 at 11:40 AM
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., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: NO PLACE LIKE HOME FOR GOLDEN AGES
FACILITY NUMBER: 197608579

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/27/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(d)
Personnel Requirements - General
(d) All personnel shall be given on the job training or have related experience in the job assigned to them. This training and/or related experience shall provide knowledge of and skill in the following, as appropriate for the job assigned and as evidenced by safe and effective job performance:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on the record review the licensee did not comply with the section cited above in there was no staff that had their training which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/11/2026
Plan of Correction
1
2
3
4
The administrator/Licensee will make sure that the all staff files have staff training for each staff present at the facility.
Type B
Section Cited
CCR
87506(b)(15)
Resident Records
(b) Each resident's record shall contain at least the following information: (15) The admission agreement and pre-admission appraisal, specified in Sections 87507, Admission Agreements and 87457, Pre-admission Appraisal.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on the record review the licensee did not comply with the section cited above in that one (1) resident out of five (5) residents did not have an admission agreement/Pre-Admission Appriasal which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/11/2026
Plan of Correction
1
2
3
4
The administrator/Licensee will make sure that one (1) resident out of the five (5) residents have their admission agreement/Pre-Admission Appriasal paperwork in their file.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Troy Agard
NAME OF LICENSING PROGRAM MANAGER:
Gina Saucedo
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/27/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/27/2026


LIC809 (FAS) - (06/04)
Page: 8 of 9
Document Has Been Signed on 04/27/2026 01:30 PM - It Cannot Be Edited


Created By: Gina Saucedo On 04/27/2026 at 11:40 AM
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., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: NO PLACE LIKE HOME FOR GOLDEN AGES
FACILITY NUMBER: 197608579

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/27/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87458(a)
Medical Assessment
(a) Prior to a person's acceptance as a resident, the licensee shall obtain documentation of a medical assessment, signed by a licensed medical professional acting within the scope of their practice and made within the last year, to be kept in the resident's record.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on the record review the licensee did not comply with the section cited above in there was one (1) physician's report/medical assessment missing from a resident which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/11/2026
Plan of Correction
1
2
3
4
The administrator/Licensee will make sure that one (1) resident out of the five (5) residents have their physician report/medical assessment paperwork in their file.
Type B
Section Cited
CCR
87463(a)
Reappraisals
(a) The pre-admission appraisal, as specified in Section 87457, Pre-Admission Appraisal, shall be updated, in writing as frequently as necessary or once every 12 months, whichever occurs first, to note significant changes in condition, as defined in Section 87101, Definitions, and to keep the appraisal accurate. For the purposes of this section, the updated pre-admission appraisal shall be referred to as the reappraisal.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on the record review, the licensee did not comply with the section cited above in two (2) out of five (5) residents were missing resident appraisal which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/11/2026
Plan of Correction
1
2
3
4
The administrator/Licensee will make sure that two (2) residents out of the five (5) residents have their resident appraisal paperwork in their file.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Troy Agard
NAME OF LICENSING PROGRAM MANAGER:
Gina Saucedo
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/27/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/27/2026


LIC809 (FAS) - (06/04)
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