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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609950
Report Date: 04/27/2026
Date Signed: 04/27/2026 04:04:04 PM

Document Has Been Signed on 04/27/2026 04:04 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:PRIME RESIDENTIAL SENIOR CAREFACILITY NUMBER:
197609950
ADMINISTRATOR/
DIRECTOR:		KHECHIKYAN, SOFYAFACILITY TYPE:
740
ADDRESS:19418 LANARK STREETTELEPHONE:
(818) 626-8553
CITY:RESEDASTATE: CAZIP CODE:
91335
CAPACITY: 6CENSUS: 6DATE:
04/27/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:45 AM
MET WITH:TIME VISIT/
INSPECTION COMPLETED:
04:30 PM
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At 9:45 AM Licensing Program Analyst (LPA), Huma Rahimi, conducted an unannounced annual inspection at the facility mentioned above. LPA met with the staff Nora Karapatyan and the Administrator was contacted via telephone. LPA explained the reason for the visit. Physical tour was conducted with the Administrator and LPA observed the following:

Kitchen: At 9:55 AM LPA toured the kitchen area and observed enough supplies of staple non-perishable for minimum 1 week and perishable for 2 days at the facility. All knives and sharps observed to be locked in a kitchen drawer. LPA observed a fire extinguisher hanging on the wall by the kitchen and was purchased on 04/27/2026.

Medications: At 10:00 AM LPA observed medications are centrally stored and locked in a closet in the hallway and inaccessible to residents in care. During the medication review, LPA could not verify the accuracy of the medication administration due to the lack of incomplete Centrally Stored Medication Record (CSMR) Form. Administrator informed LPA that the Administrator did not complete the form and was unable to provide a reason.

Bedrooms: The facility has six (6) bedrooms in total. All bedrooms were clean and odorless. Furniture was in good repair. Bedroom #3 was designated for a bedridden resident. One of the bedrooms located near the kitchen is designated for staff and LPA observed free of hazard and obstruction. LPA observed full bed rails for Resident #5 (R5), in bedroom #2 without Physician's order on file.

Continue on LIC 809C

NAME OF LICENSING PROGRAM MANAGER: Nichelle Gillyard
NAME OF LICENSING PROGRAM ANALYST: Huma Rahimi
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/27/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/27/2026
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.

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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: PRIME RESIDENTIAL SENIOR CARE
FACILITY NUMBER: 197609950
VISIT DATE: 04/27/2026
NARRATIVE
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Bathrooms: The facility had 3 bathrooms. Bathrooms #1 located by the entrance is designated for staff. All bathrooms contained paper towels and liquid soap. Bathroom #3 is attached to bedroom #6. Bathrooms have grab bars and a non-skid mat. Hot water temperature measured at 119.8°F.

Common Areas: The facility maintains a comfortable temperature at 70°F. The living room and dining area appeared clean and were properly furnished. The living room has a television, comfortable furniture. No obstructions and or tripping hazards throughout the facility.

Garage: LPA observed the garage to be locked and inaccessible to residents in care where the facility kept cleaning supplies, hazardous liquids, detergents, and extra PPE accessible to residents in care. LPA observed an extra refrigerator for staff and residents.

Laundry: The laundry is located between the kitchen and garage. LPA observed the laundry to be locked and inaccessible to residents in care.

Outside and Back Yard: LPA toured the two side paths and back yard. Both emergency exit gates were unlocked, and paths were free from debris. LPA observed appropriate outdoor furniture, with a covered shaded area for residents.

Smoke detectors/carbon monoxide. Smoke detectors were located throughout the facility, and at 10:00 AM, they were tested and observed to be operational. Carbon monoxide was living room and was also tested and observed to be operational. LPA heard functioning auditory alarms on all exit doors.

Between 11:00 AM to 1:30 PM, LPAs reviewed records of six (6) residents, two (2) staff, and the Administrator. R2's file was missing Appraisal Needs and Services Plan (LIC 625), R3's LIC 625 was last updated on 02/05/2025. R5's LIC 625 was last updated on 02/05/2025. Staff records/files were completed and updated.

On 04/15/2026, the LPA was notified via email by a credible witness of ongoing construction work on the facility’s roof. The LPA subsequently contacted the facility’s Administrator by telephone, who confirmed that the construction was being conducted due to a leak. The Administrator also confirmed that the Regional Office had not been notified prior to the construction or modification of the facility’s roof.


Continue on LIC 809C
NAME OF LICENSING PROGRAM MANAGER: Nichelle Gillyard
NAME OF LICENSING PROGRAM ANALYST: Huma Rahimi
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/27/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/27/2026
LIC809 (FAS) - (06/04)
Page: 3 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: PRIME RESIDENTIAL SENIOR CARE
FACILITY NUMBER: 197609950
VISIT DATE: 04/27/2026
NARRATIVE
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Administrative: LPA collected Certificate of Liability Insurance, and LIC500.

Deficiencies cited during today’s visit. Appeal rights issued and given.

Exit interview conducted and copy of this report signed and delivered.

NAME OF LICENSING PROGRAM MANAGER: Nichelle Gillyard
NAME OF LICENSING PROGRAM ANALYST: Huma Rahimi
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/27/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/27/2026
LIC809 (FAS) - (06/04)
Page: 4 of 7
Document Has Been Signed on 04/27/2026 04:04 PM - It Cannot Be Edited


Created By: Huma Rahimi On 04/27/2026 at 02:53 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: PRIME RESIDENTIAL SENIOR CARE
FACILITY NUMBER: 197609950

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/27/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(e)(2)
87303 Maintenance & Operation (e) Water supplies…shall be maintained…(2) Faucets used by residents…shall deliver hot water…to attain a temperature of not less than 105 degree F…and not more than 120 degree F…

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observation, the licensee did not comply with the section cited above. The water temperature was 126.1 Degrees F which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/04/2026
Plan of Correction
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Licensee shall immediately adjust hot water temperature and maintain a 5 day log to ensure hot water temperature measure within Title 22 guidelines and provide a copy of the log to the department.
Type B
Section Cited
CCR
87463(a)
Reappraisals (a)The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review and interview, the licensee did not comply with the section cited above by not having R2’s appraisals on file and not updating on R3 & R5 appraisal, which poses/posed a potential health and safety risk to residents in care.
POC Due Date: 05/04/2026
Plan of Correction
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The Licensee agreed to develop a plan to address reappraisals of residents as frequently as necessary and provide in-service training to all staff regarding the Section 87463. Proof of training and updated appraisals should be submitted to CCLD by POC date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Nichelle Gillyard
NAME OF LICENSING PROGRAM MANAGER:
Huma Rahimi
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/27/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/27/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/27/2026 04:04 PM - It Cannot Be Edited


Created By: Huma Rahimi On 04/27/2026 at 03:07 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: PRIME RESIDENTIAL SENIOR CARE
FACILITY NUMBER: 197609950

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/27/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87608(a)(5)(B)
Postural Supports. Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review the licensee did not comply with the section cited above by not obtaining a full bedrail doctor's order for R5 (who is not currently on hospice), which poses an immediate health and safety risk to residents in care.
POC Due Date: 04/28/2026
Plan of Correction
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Administrator removed full bed rails on bed's of Resident#5 (R5). The deficiency is cleared at this time.
Type A
Section Cited
CCR
87465(h)(6)(F)
87465 Incidental Medical and Dental Care
(h) The following requirements shall apply to medications which are centrally stored: (6) The licensee shall be responsible for assuring that a record of centrally stored prescriptions... (A)...(F)...


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record reviews and interviews, licensee did not comply with the section above, as facility staff handling medications were not properly documenting prescribed medications on CSMDR, which poses an immediate health and safety risk to residents in care.
POC Due Date: 04/29/2026
Plan of Correction
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Administrator agreed to schedule vendorized training for all staff by 04/29/26 and submit to CCL the vendor information and scheduled date of training. Training certifications to be submitted to CCL upon completion.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Nichelle Gillyard
NAME OF LICENSING PROGRAM MANAGER:
Huma Rahimi
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/27/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/27/2026


LIC809 (FAS) - (06/04)
Page: 6 of 7
Document Has Been Signed on 04/27/2026 04:04 PM - It Cannot Be Edited


Created By: Huma Rahimi On 04/27/2026 at 03:42 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: PRIME RESIDENTIAL SENIOR CARE
FACILITY NUMBER: 197609950

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/27/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87305(b)
Alterations to Existing Building or New Facilities: (b) The licensing agency may require the facility to acquire a local building inspection where the agency determines that a suspected hazard to health and safety exists.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interviews and e-mail notification from credible witness on 04/15/26, the licensee did not comply with the section cited above by changing/construction of the facility roof without notifying CCLD. This poses a potential health and safety risk to residents in care.
POC Due Date: 05/04/2026
Plan of Correction
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The Licensee agrees to notify and obtain approval from the licensing agency prior to any future structural modifications, alterations, or construction projects. Facility will create an internal procedure requiring administrative review and Licensing notification before initiating any physical plant changes and will submit to LPA by the POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Nichelle Gillyard
NAME OF LICENSING PROGRAM MANAGER:
Huma Rahimi
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/27/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/27/2026


LIC809 (FAS) - (06/04)
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