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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609856
Report Date: 11/06/2025
Date Signed: 11/06/2025 01:39:39 PM

Document Has Been Signed on 11/06/2025 01:39 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:WESTFIELD SENIOR LIVINGFACILITY NUMBER:
197609856
ADMINISTRATOR/
DIRECTOR:		BALASANYAN, MARIAMFACILITY TYPE:
740
ADDRESS:7633 MASON AVETELEPHONE:
(818) 384-1134
CITY:WINNETKASTATE: CAZIP CODE:
91306
CAPACITY: 6CENSUS: 4DATE:
11/06/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:56 AM
MET WITH:Champo Cilambwe - CaregiverTIME VISIT/
INSPECTION COMPLETED:
01:45 PM
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On 11/6/2025, Licensing Program Analyst (LPA) Perchui Milena Khurshudyan arrived at this facility to conduct the required Annual Inspection. Upon arrival LPA was greeted by the Caregiver Champo Chilambwe , who granted access to the facility. LPA introduced herself by showing her badge and explained the reason for the visit. The facility Administrator Mariam Balasanyan was contacted by phone and informed about the visit. LPA Khurshudyan reviewed the required postings on a wall throughout the facility. The inspection tool was used to complete today's visit.

At 10:25am LPA, with the help of the caregiver, began a physical plant tour of the facility and the following was observed: This is a single-story building with six (6) bedrooms, two (2) bathrooms, kitchen, common areas, and outdoor areas. This facility is operating as RCFE, has an approved fire clearance for six (6) non-ambulatory residents, of which one (1) may be bedridden. The facility also has approved Hospice waiver for six (6) residents.

Kitchen: LPA observed a seven-day supply of non-perishable food, and a two-day supply of perishable food properly stored and labeled. No expired food was observed. Facility stores knives and sharps inside the locked kitchen cabinet. Emergency supply of food / water was stored inside the pantry. Food storage and preparation areas are clean and inaccessible to pests. LPA observed two (2) fire extinguishers in the facility, one (1) located in the hallway, and one (1) next to the kitchen area with a last service date 11/6/2025. A weekly menu was also available for clients and was posted on the fridge.

Bedrooms: There are six (6) bedrooms in the facility designated for residents’ use, the office is in the living area. All bedrooms are for private use. LPA observed bedrooms to be properly furnished with beds, linens, night stands, chairs, drawers, closets, and adequate lighting. All bedrooms appeared organized and clean.

Continue on LIC809-C

NAME OF LICENSING PROGRAM MANAGER: Nichelle Gillyard
NAME OF LICENSING PROGRAM ANALYST: Perchui Khurshudyan
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 11/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/06/2025
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 4
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: WESTFIELD SENIOR LIVING
FACILITY NUMBER: 197609856
VISIT DATE: 11/06/2025
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Common Areas: These include living and dining areas. LPA observed dining, living areas clean and clear of clutter. Furniture is generally new and in a good repair. Dining and living room furniture sits at the capacity of the facility. Walls, floors, windows, screens, and blinds were clean and in good repair. At 11:00am LPA measured the room temperature to be 72 degrees Fahrenheit. There is a linen closet with an adequate supply of fresh linens ready to use. No obstructions and or tripping hazards found throughout the facility. Facility has landline, LPA checked it was operational. There is a television, cabinet for activities, and art supplies available for clients’ use.

Bathroom: There are two (2) bathrooms in the facility. The bathrooms contained hand soap, paper towels, toilet paper and trash bins with lids. The hot water temperature was measured at approximately 11:15am to be 117.9 degrees Fahrenheit. LPA also observed required signs on the bathroom walls and non-skid mats inside the showers.

Smoke and Carbon Monoxide Detectors: The smoke and carbon monoxide detectors were tested by staff at 11:25am and were observed to be operational.

Garage: There is no garage on the property.

Laundry Room: Functioning washer and dryer located in the backyard, inside a separated space. Laundry detergents and other chemical supplies are locked inside the cabinets placed in the laundry space. LPA observed all chemicals were inaccessible to residents in care.

Backyard: The backyard is fenced and has sufficient yard space. Appropriately covered shaded area available for residents use. LPA discussed the importance of maintaining care and supervision to meet the needs of clients. Entry / Exit doors were unlocked and free of obstructions. There is no body of water in the property.

Staff/Client File review: Facility records are kept inside the locked commercial cabinets located in the office area. Between 11:30am -12:35pm LPA conducted records review of three (3) staff files and four (4) residents’ records. Files were complete and updated.

Continue on LIC809-C

NAME OF LICENSING PROGRAM MANAGER: Nichelle Gillyard
NAME OF LICENSING PROGRAM ANALYST: Perchui Khurshudyan
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 11/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2025
LIC809 (FAS) - (06/04)
Page: 3 of 4
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: WESTFIELD SENIOR LIVING
FACILITY NUMBER: 197609856
VISIT DATE: 11/06/2025
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Medications: At approximately 12:45pm. LPA reviewed Centrally Stored Medication Destruction Records for proper documentation. The facility also maintains Medical Administration Records (MAR). LPA observed centrally stored medications locked inside the kitchen cabinet and inaccessible to residents in care. Complete First-aid kit is in the office area, new manual for first aid kit was also available. No potentially dangerous items were found in the facility. The facility operates with two (2) shifts and has one to three (1-3) staff members for each shift.

Three out of four residents were present during the visit; LPA interviewed Administrator, Caregiver, and three (3) residents.

Facility plan/sketch is posted on the entrance wall along with other posting requirements.

LPA collected LIC500, LIC9020, the Copy of Administrator Certificate, and a copy of the Liability Insurance Ex. 12/20/2025.

The Administrator's certificate - Exp date is 1/16/2027.

No citations issued during today's visit.

Exit interview conducted. Copy of this report provided.

NAME OF LICENSING PROGRAM MANAGER: Nichelle Gillyard
NAME OF LICENSING PROGRAM ANALYST: Perchui Khurshudyan
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 11/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2025
LIC809 (FAS) - (06/04)
Page: 4 of 4