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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608585
Report Date: 05/14/2026
Date Signed: 05/14/2026 01:50:48 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 05/14/2026 01:50 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:BUENA VISTA VILLA RCFEFACILITY NUMBER:
197608585
ADMINISTRATOR/
DIRECTOR:		GAYANE DZHAGARYANFACILITY TYPE:
740
ADDRESS:2741 N. BUENA VISTA STREETTELEPHONE:
(818) 478-1357
CITY:BURBANKSTATE: CAZIP CODE:
91504
CAPACITY: 6CENSUS: 6DATE:
05/14/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Michael Petrosian-AdministratorTIME VISIT/
INSPECTION COMPLETED:
01:45 PM
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Licensing Program Analyst (LPA) Nadia Shahbazian conducted an Annual Required visit and inspection of the facility. LPA met with Administrator - Michael Petrosian and explained the reason for the visit. The Residential Care Facility for the Elderly (RCFE) is licensed to serve (6) Non-Ambulatory clients with hospice waiver for three (3). Current census is six (6) and all clients are receiving services through Frank D. Lanterman Regional Center.

At 11:20am, with the assistance of administrator, LPA took a tour of the physical plant. Required postings were observed on the hallway wall. The smoke and carbon monoxide detectors are hardwired and interconnected. At 9:48am smoke/carbon monoxide detectors were tested and observed to function properly. The fire extinguisher is located in the kitchen and was purchased on 01/15/2026. Facility conducts emergency drills quarterly, the last Fire Drill was conducted on 05/04/2026 and the last earthquake drill was conducted on 03/02/2026. There are two exits, one in the kitchen (with three stairs) and the other is located by the kitchen, with a ramp leading to the rear sliding door. Facility uses the rear sliding door as the emergency exit, leading to the back alley.

Common Areas: Living room is located by the entry door and leads to the dining room. Common areas were checked for cleanliness. There is a television set and cabinets containing games and art supplies in the living room. There is also a non-functional, screened fireplace in the living room. The furniture was observed to be clean and in good repair and included a dining table, coffee table, couches/chairs, sufficient for the capacity of the facility.

Kitchen: The kitchen appliances and work surfaces are clean and sanitary. Facility has sufficient supply of perishable (2 days) and non-perishable (7 days) foods at the facility. Knives were stored in a locked drawer in the kitchen and a water filtering system was observed underneath the sink.

NAME OF LICENSING PROGRAM MANAGER: Mary G Flores
NAME OF LICENSING PROGRAM ANALYST: Nadia Shahbazian
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/14/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/14/2026
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 S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: BUENA VISTA VILLA RCFE
FACILITY NUMBER: 197608585
VISIT DATE: 05/14/2026
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Bedrooms: There are three (03) shared bedrooms designated for clients' use. Bedrooms # 2 and #3 are next to each other and bedroom #1 is near the kitchen. The bedrooms were observed to be clean and clear of clutter, properly furnished with appropriate beds, night stands and chairs.

Bathrooms: There are two (02) bathrooms designated for clients' use. Bathrooms had functional fixtures, grab bars and non-skid mats. The hot water temperature measured between 111 and 113.2 degrees Fahrenheit, within regulation.

Surrounding Grounds: LPA observed that the entry/exits were free of obstruction. There is a covered area, for residents to use and furniture appropriate for outdoor use. The backyard is sufficient in space for outdoor exercise and activities. The facility has a detached garage, in the back, which is kept locked. The washer and dryer, cleaning products, kitchen detergents and chemicals are kept in the locked garage. LPA observed emergency food, water and an extra refrigerator, in the garage, to store an over flow of food for residents.

Client/Staff Records: All records were kept locked in the office, which is located across the entry door. Six (06) out of six (06) client records were reviewed and observed to be complete and up-to-date physician records. P&I for all six (6) clients were counted and compared to receipts. Staff records for four (4) staff members were reviewed for compliance and current training and first aid/CPR certification.

Medications: Two complete first aid kits, first aid manual and all medications are kept locked in a hallway closet. Medications for three (3) out of six (6) clients were counted and compared to Medication Administration Records (MAR) for accuracy of administration, based on physician orders.

Operational Requirements: Liability Insurance was reviewed with expiration date of 06/12/2026, in the amount of at least ($1,000,000) per occurrence and ($3,000,000) in total annual aggregate is in place. Surety Bond was reviewed with expiration date of 11/12/2026, approved in the amount of $10,000.00. Administrator Certificate expiration date is 08/10/2027. Infection Control Plan and Emergency and Disaster Plan was also reviewed.

Pursuant to Title 22 Division 6 of the CA Code of Regulations, no deficiencies observed during the visit.

Exit Interview Conducted / A Copy of the Report provided.

NAME OF LICENSING PROGRAM MANAGER: Mary G Flores
NAME OF LICENSING PROGRAM ANALYST: Nadia Shahbazian
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/14/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/14/2026
LIC809 (FAS) - (06/04)
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