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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610002
Report Date: 08/20/2025
Date Signed: 08/20/2025 06:36:22 PM

Document Has Been Signed on 08/20/2025 06:36 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 N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:JASMINEFACILITY NUMBER:
197610002
ADMINISTRATOR/
DIRECTOR:		SARGSYAN, ARMANFACILITY TYPE:
740
ADDRESS:7331 KATHERINE AVETELEPHONE:
(818) 785-4230
CITY:VAN NUYSSTATE: CAZIP CODE:
91405
CAPACITY: 6CENSUS: 5DATE:
08/20/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:11 AM
MET WITH:Jasmine Sargsyan, LicenseeTIME VISIT/
INSPECTION COMPLETED:
06:40 PM
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Licensing Program Analyst(LPA) Christine Yee conducted an unannounced required Annual Inspection using the complete CARE Inspection Tool. LPA Yee met with Jasmine Sargsyan, Licensee and the reason for today's visit was provided. Arman Sargsyan, Administrator was out of town and did not participate in todays visit..

The facility is a single storey home consisting of a living room, dining room, kitchen, 3 bedrooms, 3 full bathrooms and a attached garage that was converted into a office/living quarters. The facility is fire cleared for 6 non-ambulatory residents only.

All 12 domains of the CARE Inspection Tool was reviewed on today's visit. Also reviewed on today's visit were all 5 resident files and 6 staff files.
The following was observed on today's visit:
  • the living room, dining room and kitchen were furnished and equipped with the appropriate furniture and equipment for its designated use and for the licensed capacity. The fire place in the front room was observed with a fire screen.
  • The only fire extinguisher is located in the laundry room, located next to the kitchen, was last serviced on 7/29/25.
  • Sufficient perishable foods for a minimum of 2 days and non-perishable foods for a minimum of 7 days were observed.
  • Sharp knives are stored in a locked kitchen drawer

continued on LIC809
NAME OF LICENSING PROGRAM MANAGER: Kristin Heffernan
NAME OF LICENSING PROGRAM ANALYST: Christine Yee
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 08/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/20/2025
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.

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 N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: JASMINE
FACILITY NUMBER: 197610002
VISIT DATE: 08/20/2025
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  • Soap, cleaning solutions, hygiene products are stored in a locked cabinet in the laundry room. Additional hygiene products are also stored in the common bathroom located by bedroom #3
  • All three bedrooms were furnished with 2 each of the following: 2 hospital beds, 2 chairs, 2 night stands, 2 lamps, 2 dressers and a shared built in closet..
  • The common bathroom by the front room has a toilet, a single sink vanity and a tub with a shower. Grab bars, a shower chair and a slip resident mat was observed. Water temperature was tested and read 115.7 degrees Fahrenheit.
  • The common bathroom located by bedroom #3 has a walk in shower with grab bars, shower chair, slip resident mat, a toilet with a riser, and a single sink vanity. Water temperature was tested and read 112.3 degrees Fahrenheit.
  • The third full bathroom located by the front door is designated for staff use.
  • The first aid kit was reviewed and contained gauze, bandages, band aid, a tweezer and a pair of scissors. An external thermometer was also observed.
  • Medications are stored in a locked cabinet in the living room.
  • Oxygen is in use in the home and signs were posted. However, it was suggested that larger signs be posted so it is more visible. Per Licensee, a written notice was sent to the local fire department.
  • The required posters were observed.
  • The garage was also toured and is still being used as an office and for staff use.
  • the hardwired smoke detectors and combination smoke/carbon monoxide detectors located inside the resident rooms, resident hallway and in the dining room were tested and were operational.
  • the auditory devices on the outside exiting doors located in bedroom #3, front door and the 2 sliding glass doors in the living room were tested and were operational.
  • The window screens in bedroom #2 and common bathroom are warped and missing a screen, bedroom #3 is missing a screen and the sliding screen door is warped. Per Licensee, new screens were ordered and the vendor was supposed to replace the screens on 8/19/25 and did not show up as scheduled. Copy of the emailed appointment confirmation was obtained. The Licensee was given 2 weeks(9/3/25) to resolve installation with the vendor and provide evidence of completion.
  • Located in the backyard is a detached covered patio furnished with wicker chairs and a coffee table. The backyard was observed to be clean
  • The front yard was also toured and it was observed to be clean. Trash cans were observed on the curb for pickup for the following day.
Exit interview was conducted.
NAME OF LICENSING PROGRAM MANAGER: Kristin Heffernan
NAME OF LICENSING PROGRAM ANALYST: Christine Yee
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2025
LIC809 (FAS) - (06/04)
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