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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609882
Report Date: 10/17/2025
Date Signed: 10/17/2025 01:16:56 PM

Document Has Been Signed on 10/17/2025 01:16 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.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:4TH GENERATION SENIOR LIVING INC.FACILITY NUMBER:
197609882
ADMINISTRATOR/
DIRECTOR:		MANAHAN, JASMINFACILITY TYPE:
740
ADDRESS:23259 VICTORY BLVDTELEPHONE:
(747) 226-0923
CITY:WEST HILLSSTATE: CAZIP CODE:
91307
CAPACITY: 6CENSUS: 5DATE:
10/17/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Jasmin ManahanTIME VISIT/
INSPECTION COMPLETED:
01:30 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 approximately 9:00 a.m. on 10/17/25 Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced annual visit. LPA met with the administrator and disclosed the reason for the visit.

The facility was last visited on 07/17/25 for a complaint visit. It is a single story building with seven (07) bedrooms, three (03) bathrooms, kitchen, common areas, and outdoor areas. It has an approved fire clearance for six (06) nonambulatory residents, of which one (01) may be bedridden. The facility serves residents with dementia. Approved hospice waivers for five (05). Surveillance cameras are used in common areas.

The front entrance was gated and unlocked. The front yard was maintained with gardened areas and free of hazards. At the front door, LPA observed postings for the house rules, visitation policy, facility sketch, facility license, COVID precautions, rights of resident councils, personal rights, ombudsman contacts, emergency disaster plan, personal rights, and administrator certificates. A screening station at the front contained a visitor log, sanitizer, digital thermometer, and masks.

Walls, floors, windows, screens, and blinds were clean and in good repair. At 9:10 a.m. LPA measured the room temperature to be 72 degrees Fahrenheit. The living room contained a television, reading materials, and furniture in good repair. Activities were set up on the dining room table. Hallway closets contained adequate supplies of fresh linens and extra supplies. A locked closet near the main entrance contained confidential files, medications, and a fully-stocked first aid kit. At 9:20 a.m. LPA successfully called out from the house telephone and deemed it operational.

NAME OF LICENSING PROGRAM MANAGER: Naira Margaryan
NAME OF LICENSING PROGRAM ANALYST: Nicholas Reed
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 10/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/17/2025
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 3
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)
Page: 2 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: 4TH GENERATION SENIOR LIVING INC.
FACILITY NUMBER: 197609882
VISIT DATE: 10/17/2025
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 facility has seven (07) bedrooms. One (01) bedroom served as a staff room. The staff room was free of hazards. All bedrooms contained a chair, lamp, nightstand, storage, and a bed with adequate bedding. All furnishings were clean and in good condition. Exit doors from rooms were unlocked. A resident in Bedroom #3 had full bed rails.

The facility has three (03) bathrooms. Two (02) bathrooms are private, and one (01) is shared. Bathrooms contained liquid soap, trash cans with tight fitting lids, bidets, grab bars near the toilet and shower, and a non-skid mat in the shower. At approximately 9:30 a.m. LPA measured the water temperature in the shared bathroom to be 118.2 degrees Fahrenheit.

LPA observed an adequate supply of perishable and non-perishable foods in the kitchen refrigerators, freezers, and pantry. A weekly menu was posted on the refrigerator. At 11:35 a.m. LPA measured the refrigerator temperature to be 34 degrees Fahrenheit. Appliances were clean and in good condition. Sharps were locked below the counter top. Cleaning solutions and detergents were locked in the laundry area adjacent to the kitchen. The laundry area contained a washing machine and a dryer in working order.

At 11:40 a.m. LPA observed three (03) residents in the living room watching television. Lunch was served at 11:45 a.m. Lunch was observed to contain a variety of nutritious proteins, fruits, and grains. LPA overheard the administrator offering residents multiple choices for lunch.

At 12:45 p.m. the combination carbon monoxide and smoke detectors were tested and operational. At 12:55 p.m. a fully-charged fire extinguisher was observed in the kitchen. Four (04) out of four (04) auditory alarms were on and functional. Two (02) seating areas in the rear were shaded with furniture in good repair. One of the seating areas had a mosquito net around it. The back yard also contained a gardened area, exercise equipment, and a gas grill. The garage was locked and contained tools and extra supplies. A shed was also locked and contained additional supplies. The emergency exit path was free of hazards. The exit gate was unlocked.

At 12:30 p.m. LPA conducted a records review of resident and personnel files. All files were complete and available for audit.

During today’s inspection, no immediate health or safety hazards were observed.

Exit interview conducted. Copy of report provided.

NAME OF LICENSING PROGRAM MANAGER: Naira Margaryan
NAME OF LICENSING PROGRAM ANALYST: Nicholas Reed
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2025
LIC809 (FAS) - (06/04)
Page: 3 of 3