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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609508
Report Date: 03/04/2026
Date Signed: 03/04/2026 12:20:35 PM

Document Has Been Signed on 03/04/2026 12:20 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:MOUNTAIN VILLAFACILITY NUMBER:
197609508
ADMINISTRATOR/
DIRECTOR:		NARINE SARYANFACILITY TYPE:
740
ADDRESS:1845 W. MOUNTAIN STREETTELEPHONE:
(818) 945-5644
CITY:GLENDALESTATE: CAZIP CODE:
91201
CAPACITY: 6CENSUS: 5DATE:
03/04/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Narine Saroyan, AdministratorTIME VISIT/
INSPECTION COMPLETED:
12:45 PM
NARRATIVE
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On 03/04/26, at 09:30am, Licensing Program Analyst (LPA) Gina Saucedo arrived at the facility to conduct an unannounced, annual visit. Victoria Atufula, Caregiver was advised of the visit. Narine Saroyan, Administrator was called and arrived about fifteen(15) minutes later.

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

The facility is a one (1) story home that has a total of six (06) bedrooms and four (04) bathrooms. The facility is fire cleared for six (06) non-ambulatory and a hospice waiver for four (04).

Last fire drill/Fire Alarms were conducted on 02/2026. The living and dining room are neat and clean. The smoke and carbon monoxide detectors are hardwired, interconnected and observed to be operational. Fire extinguisher is located near the kitchen, observed to be full and last purchased on 03/06/2025. There are cameras in the common areas.


Kitchen is sufficiently stocked with at least two (02) days perishable and seven (07) days non-perishable food. Frozen foods are wrapped and stored appropriately. Kitchen cabinets contain extra food. Knives and sharps are observed to be locked and inaccessible to residents in one (1) of the top cabinets. The medication is kept next to the kitchen area locked and inaccessible to the residents in a pantry area. The washer and dryer with toxins are kept in this same area in a pantry area locked and inaccessible to residents.

LIC 809C-continued
NAME OF LICENSING PROGRAM MANAGER: Troy Agard
NAME OF LICENSING PROGRAM ANALYST: Gina Saucedo
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 03/04/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/04/2026
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 5
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: MOUNTAIN VILLA
FACILITY NUMBER: 197609508
VISIT DATE: 03/04/2026
NARRATIVE
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Living Room and Dining Room: LPA observed the living room and furniture to be clean and in good repair. LPA observed the dining area to be clean and in good repair. The dining room area has five (5) chairs for residents and a television. The facility temperature is at 74 degrees Fahrenheit.

The fire extinguisher was observed to be fully charged and located in the kitchen area.

Bedrooms: Facility has six (6) bedrooms and were toured. The bedrooms are fully furnished with proper lighting and bedding. Two (2) bedrooms are currently empty and three (3) bedrooms are single, occupied and one (1) is shared.

Bathrooms: There are four (4) bathrooms that have proper grab bars, non-skid mats. The bathrooms contained a trash can with tight-fitting lid. Three (3) bathrooms are private and the other is in the hallway. Hot water was tested and measured 114F, 113.8F within regulations.

Outside/Backyard: There is no garage. There is one (1) shed in the backyard. The outside/backyard has furniture for residents to have proper seating. There is a pool that is not filled and is inaccessible to the residents it is locked.

Administrative: The administrative Certification is current and expires 02/14/2028. There is a yes sign, Ombudsman, Personal Rights and Emergency Disaster Plan against the entrance of the facility on your right-hand side. There was no proof of liability insurance.

Staff/Resident Files: LPA reviewed five (5) resident files. Four (4) out of the five (5) resident files were missing Physician's signature and diagnosis of resident. LPA reviewed three (3) staff files. Two (2) out of the three (3) files were missing CPR-Cadiopulmonary Resuscitation.

An exit interview was conducted, citation(s) were issued, appeals rights 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: 03/04/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2026
LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 03/04/2026 12:20 PM - It Cannot Be Edited


Created By: Gina Saucedo On 03/04/2026 at 11:44 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: MOUNTAIN VILLA
FACILITY NUMBER: 197609508

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/04/2026

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 interview and record review the licensee did not comply with the section cited above in which there was no proof of liability insurance which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/18/2026
Plan of Correction
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The administrator/Licensee shall send the proof of liability insurance to LPA.
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 two (2) out of three (3) staff did not have CPR which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/18/2026
Plan of Correction
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The administrator/Licensee shall send the proof of CPR to LPA.
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: 03/04/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/04/2026


LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 03/04/2026 12:20 PM - It Cannot Be Edited


Created By: Gina Saucedo On 03/04/2026 at 11:44 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: MOUNTAIN VILLA
FACILITY NUMBER: 197609508

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/04/2026

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
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Based on the record review the licensee did not comply with the section cited above in four (4) out of five (5) residents did not have the medical assessment signed by a physician which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/18/2026
Plan of Correction
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The administrator/Licensee shall send proof of medical assessent signed by a physician to LPA.
Type B
Section Cited
CCR
87458(c)(1)
Medical Assessment
(c) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the licensed medical professional's diagnosis or diagnoses and results of an examination for all of the following:

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 which four (4) out of five (5) residents did not have a diagnosis written on the medical assessment which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/18/2026
Plan of Correction
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The administrator/Licensee shall send proof of medical diagnosis on medical assessent signed by a physician to LPA.
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: 03/04/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/04/2026


LIC809 (FAS) - (06/04)
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