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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608756
Report Date: 09/26/2025
Date Signed: 09/26/2025 03:01:46 PM

Document Has Been Signed on 09/26/2025 03:01 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:ANGEL LIFE CAREFACILITY NUMBER:
197608756
ADMINISTRATOR/
DIRECTOR:
MICHAEL PETROSIANFACILITY TYPE:
740
ADDRESS:407 ETON DRIVETELEPHONE:
(818) 478-1792
CITY:BURBANKSTATE: CAZIP CODE:
91504
CAPACITY: 6CENSUS: 6DATE:
09/26/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:30 AM
MET WITH:Michael Petrosian-AdministratorTIME VISIT/
INSPECTION COMPLETED:
02:45 PM
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Licensing Program Analyst (LPA) Nadia Shahbazian conducted an Annual Required visit and inspection of the facility. LPA met with Administator - Michael Petrosian and explained the reason for the visit. The facility is licensed to serve Elderly residents ages 60 and above with developmental disabilities Facility is approved to serve (6) Non-Ambulatory residents, of which (6) may be Bedridden, with hospice waiver for (6) The home is vendorized by Frank D. Lanterman Regional Center.

At 11:45am, with the assistance of administrator, LPA took a tour of the physical plant. Required postings were observed in the hallway. The smoke and carbon monoxide detectors are hardwired and interconnected. At 10:18am smoke/carbon monoxide detectors were tested and observed to function properly. The fire extinguishers are located in the kitchen and the hallway, both purchased on 01/28/2025.

Kitchen: The kitchen appliances and work surfaces are clean and sanitary, all appliances were observed to be functional. LPA found a 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. There is a dining set on one corner of the kitchen.

Bedrooms: There were five (5) bedrooms designated for residents' use. All of the bedrooms, in use by residents were were properly furnished with appropriate beddings and linens with sufficient lighting.

Bathrooms: There are two (2) bathrooms designated for residents' use. Both bathrooms had required functional fixtures, grab bars and non-kid mats. Hot water temperature was measured at 107.2 and 109.4 degrees Fahrenheit.

Continue on 809-C
NAME OF LICENSING PROGRAM MANAGER: Troy Agard
NAME OF LICENSING PROGRAM ANALYST: Nadia Shahbazian
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/26/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/26/2025
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 S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: ANGEL LIFE CARE
FACILITY NUMBER: 197608756
VISIT DATE: 09/26/2025
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Common Areas: These included the dining area in kitchen, living room and dining room. There is a non-functional fireplace in the living room, behind a sofa, inaccessible to residents in care. In the living room, there are games, television, cable and internet access for clients' use. The common areas were properly furnished with ample seating for all residents and staff.

Surrounding Grounds: There are no bodies of water present. There are exit doors in each bedroom, and in the hallway, leading to the backyard. Facility uses the side gate as the main emergency exit. All walkways and exit passages were free of obstruction. There is a covered patio with two sets of furniture, appropriate for outdoor use. There is a detached garage, currently used as storage. LPA observed a freezer and refrigerator, stocked with clearly marked perishable food supplies in the garage. There are locked cabinets for storage of chemicals and detergents in the garage. Attached to the garage, there is a room, only used as storage and is kept locked, inaccessible to residents..

Laundry Room: Washer and dryer are located in the laundry room, next to bedroom #5. Chemicals and detergents are locked in the laundry room, inaccessible to residents.

Medications: Medication and Medication Records are kept locked in a hallway closet. Medications for 3 out of 6 residents were counted and records were reviewed for accuracy of administration.

Resident Files: LPA conducted a file review of all 6 resident records to ensure compliance of licensing forms and current physician records.

Staff Files: LPA conducted a file review of staff records to ensure forms and training are up to date and compliant with licensing forms.

Operational Requirement: Liability Insurance was reviewed with expiration date of 10/26/2026, 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. Facility conducts quarterly emergency drills; the last fire drill was conducted on 08/01/2025 and earthquake drill was conducted on 07/01/2025.

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 Issued.

NAME OF LICENSING PROGRAM MANAGER: Troy Agard
NAME OF LICENSING PROGRAM ANALYST: Nadia Shahbazian
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/26/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2025
LIC809 (FAS) - (06/04)
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