<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609135
Report Date: 02/11/2025
Date Signed: 02/11/2025 06:20:49 PM

Document Has Been Signed on 02/11/2025 06:20 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:BURBANK HILLS COMFORT LIVINGFACILITY NUMBER:
197609135
ADMINISTRATOR/
DIRECTOR:		HANNESYAN, NARINEFACILITY TYPE:
740
ADDRESS:2745 N MYERS STTELEPHONE:
(818) 736-5097
CITY:BURBANKSTATE: CAZIP CODE:
91504
CAPACITY: 6CENSUS: 4DATE:
02/11/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Narine Hannesyan/AdministratorTIME VISIT/
INSPECTION COMPLETED:
06:00 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
At 10:00 AM Licensing Program Analysts (LPAs), Nadia Shahbazian and Evelin Rios, conducted an unannounced annual inspection at the facility. LPAs met with the staff and explained the reason for the visit. LPA requested the staff to contact the administrator, Narine Hannesyan, who was not in the facility. Later on the staff received a call from administrator’s son, Sam, informing that administrator is unable to meet at this time. Sam provided information and stated the current census is 4.

At approximately 10:30 am LPAs conducted a physical plant tour and observed the following:

The total capacity of the facility is approved for six (6) residents; LPAs observed four (4) residents. LPAs were informed that resident in room three (3) passed away approximately a month ago. LIC 624A Death Report was not submitted to CCLD.

Common Areas: The entry hall was furnished with a dresser. LPAs observed a complete first aid kit in the drawer but there was no first aid manual. LPAs observed three (3) scissors and two (2) sharp nail clippers in an unlocked drawer, accessible to the residents. The living room and dining area is a large space, with the office space in the corner of the dining room. The office area included the telephone for resident use. The living area appeared to be clean and was properly furnished with seating for the capacity of the facility.

Continued on LIC 809C

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Nadia Shahbazian
LICENSING EVALUATOR SIGNATURE: DATE: 02/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/11/2025
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 7
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: BURBANK HILLS COMFORT LIVING
FACILITY NUMBER: 197609135
VISIT DATE: 02/11/2025
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
26
27
28
29
30
31
32
The living room has a television set and a fireplace, secured with a screen. LPAs observed a refrigerator in the dining room with a fully charged fire extinguisher on top of the refrigerator. The dining room was equipped with a sliding door which faced a fenced pool and the backyard area but had no stairs, leading down to the outside. The staff informed LPAs that the sliding door does not open, therefore it is not utilized as an exit door. LPAs observed damage on the ceiling of the hallway leading to the bedrooms, in addition the LPAs observed the filter in the hallway to be covered by dust. Currently the main entry door and bedroom #3 and #4 are designated as fire exits but none of the doors were observed to have functional auditory alarms. All exit doors were observed to be free of hazard and obstruction. The facility maintains a comfortable temperature at 73°F.

Bedrooms: The facility has four (4) bedrooms in total. All bedrooms were clean, furnished with dresser drawers and chairs with ample lighting and bedding for the residents. Currently no bedroom has been designated for a bedridden resident. Bedroom #1 is private and was in good repair, except for a tear in the window screen. Bedroom #4 is shared currently. Bedroom #2 is private with its own private bathroom. LPAs observed a freezer inside bedroom #2 which included perishable foods for the facility. Bedroom #3 is currently vacant since the resident passed away recently. LPAs observed a bedroom by the dining room currently designated for staff, although the facility sketch designates it as an office and not a bedroom.

Bathrooms: The facility had two (2) bathrooms, one shared for residents and the other located in bedroom #2 for private use. LPAs observed grooming items and one razor inside the private bathroom of bedroom #2. All bathrooms contained paper towels and liquid soap. Bathrooms have grab bars and a non-skid floors. Hot water temperature was taken from both bathrooms and was measured between 113.2 and 113.7 Fahrenheit within regulation.

Continued on LIC 809C

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Nadia Shahbazian
LICENSING EVALUATOR SIGNATURE:

DATE: 02/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/11/2025
LIC809 (FAS) - (06/04)
Page: 2 of 7
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: BURBANK HILLS COMFORT LIVING
FACILITY NUMBER: 197609135
VISIT DATE: 02/11/2025
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
26
27
28
29
30
31
32
Kitchen: LPAs observed ample supplies and dishes. All knives and sharp objects were observed to be locked in a kitchen drawer. There were ample supply of staple non-perishable food for minimum 1 week and perishable for 2 days at the facility.

Laundry: LPAs observed an unlocked shed in the backyard, where the washer and dryer were located. The door of the shed was broken and the laundry detergent/chemicals were accessible to residents.

Outside and Back Yard: There was a fenced pool in the backyard. The garage has been converted to a dwelling and is privately occupied. LPAs observed appropriate outdoor furniture, with a covered shaded area for residents. Emergency exit gate was kept unlocked and the path was free from debris.

Smoke detectors/carbon monoxide. Smoke detectors were located throughout the facility but the one in hallway and in bedroom #1 were dismantled and non-operational. At 11:00 AM, smoke detectors were tested and observed to be operational. Carbon monoxide detectors were not observed.

Administrator arrived to the facility to provide records. LPA were unable to review any staff, resident records or medication documentation at this time, due to time constraints. LPAs were unable to complete the annual visit. An unannounced follow-up visit will be conducted at a later date to complete the annual inspection.


Deficiencies Cited (Refer to LIC809-D). Exit interview conducted. Appeal rights and copy of report provided to administrator.
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Nadia Shahbazian
LICENSING EVALUATOR SIGNATURE:

DATE: 02/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/11/2025
LIC809 (FAS) - (06/04)
Page: 3 of 7
Document Has Been Signed on 02/11/2025 06:20 PM - It Cannot Be Edited


Created By: Nadia Shahbazian On 02/11/2025 at 04:59 PM
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: BURBANK HILLS COMFORT LIVING
FACILITY NUMBER: 197609135

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/11/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1569.311
Regulations
Every residential care facility for the elderly shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 of Division 12. The department shall account for the presence of these detectors during inspections.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and interview, the licensee did not comply with the section cited above in not having carbon monoxide detector, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/12/2025
Plan of Correction
1
2
3
4
Licensee immediately purchased the corbon monoxide detector and provided a receipt to LPA. Licensee will submit a picture of the carbon monoxide detector after installation.
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
1
2
3
4
Based on observation the licensee did not comply with the section cited above in having sharp objects accessable to residents which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/12/2025
Plan of Correction
1
2
3
4
Staff immediately removed the sharp objects. Licensee will provide a statement of understanding of the regulation cited by POC due date of 02/12/2025 to ensure that all such items are kept locked.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Eva Miller
LICENSING EVALUATOR NAME:Nadia Shahbazian
LICENSING EVALUATOR SIGNATURE:
DATE: 02/11/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/11/2025


LIC809 (FAS) - (06/04)
Page: 4 of 7
Document Has Been Signed on 02/11/2025 06:20 PM - It Cannot Be Edited


Created By: Nadia Shahbazian On 02/11/2025 at 04:59 PM
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: BURBANK HILLS COMFORT LIVING
FACILITY NUMBER: 197609135

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/11/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87208(a)
Plan of Operation
(a) The licensee shall have and maintain a current, written definitive plan of operation for the facility. The licensee shall operate the facility in accordance with the terms specified in the plan of operation and may be cited for not doing so pursuant to Health and Safety Code section 1569.49. The plan and related materials shall be on file in the facility and shall be submitted to the licensing agency with the license application. Any significant changes in the plan of operation which would affect the services to residents shall be submitted to the licensing agency for approval. The plan and related materials shall contain the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and record review, the licensee did not comply with the section cited above in providing an updated facility sketch to CCLD with changes regarding room changes which posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/28/2025
Plan of Correction
1
2
3
4
Licensee will submit an updated facility sketch with current office/staff room, bedridden designated rooms and the ADU permit.
Type B
Section Cited
CCR
87211(a)(1)
Reporting Requirements
(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on interview with staff and record review, the licensee did not comply with the section cited above in regarding to death report of one resident, which posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/18/2025
Plan of Correction
1
2
3
4
Licensee will submit a Death Report to CCLD, along with copy of the death certificate.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Eva Miller
LICENSING EVALUATOR NAME:Nadia Shahbazian
LICENSING EVALUATOR SIGNATURE:
DATE: 02/11/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/11/2025


LIC809 (FAS) - (06/04)
Page: 5 of 7
Document Has Been Signed on 02/11/2025 06:20 PM - It Cannot Be Edited


Created By: Nadia Shahbazian On 02/11/2025 at 04:59 PM
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: BURBANK HILLS COMFORT LIVING
FACILITY NUMBER: 197609135

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/11/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in regards to a broken shed door, ceiling damages, air filter dust, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/11/2025
Plan of Correction
1
2
3
4
Licensee will repair the damaged areas and will provide the pictures of the completed work by the POC due date. Licensee will ensure that the facility stays in good repair.
Type B
Section Cited
CCR
87303(c)
Maintenance and Operation
(c) All window screens shall be clean and maintained in good repair.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in having a torn window screen, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/11/2025
Plan of Correction
1
2
3
4
Licensee will repair/replace the window screen and will provide the pictures of the completed work by the POC due date. Licensee will ensure that the facility stays in good repair.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Eva Miller
LICENSING EVALUATOR NAME:Nadia Shahbazian
LICENSING EVALUATOR SIGNATURE:
DATE: 02/11/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/11/2025


LIC809 (FAS) - (06/04)
Page: 6 of 7