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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610051
Report Date: 04/30/2026
Date Signed: 04/30/2026 05:05:18 PM

Document Has Been Signed on 04/30/2026 05:05 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:VALLEY VILLAGE SENIOR LIVING, INC.FACILITY NUMBER:
197610051
ADMINISTRATOR/
DIRECTOR:		AYVAZYAN, SARGISFACILITY TYPE:
740
ADDRESS:5541 VANTAGE AVE.TELEPHONE:
(818) 301-7551
CITY:VALLEY VILLAGESTATE: CAZIP CODE:
91607
CAPACITY: 6CENSUS: 6DATE:
04/30/2026
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:44 PM
MET WITH:Sargis AyvazyanTIME VISIT/
INSPECTION COMPLETED:
05:15 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Angela Barutyan and Quoc Huynh conducted a Case Management - Deficiencies visit in conjunction with a complaint visit (Complaint Control #29-AS-20260429152318). The purpose of the visit is to issue citations for deficiencies observed during the initial complaint investigation.

During the visit on 04/30/2026, LPAs observed Staff #1 (S1) and Staff #2 (S2) without a criminal record clearance transfer. Staff and Administrator Sargis Ayvazyan stated that S1 has been working at the facility for a few months and S2 started today on 04/30/2026.

Upon record review, LPAs observed that incident and death reports for Resident #1 (R1) were not submitted to the Woodland Hills North Regional Office. The Administrator stated that the incident report of R1’s hospitalization was submitted via email but was unable to provide proof. The Administrator additionally confirmed that R1’s death report was not submitted.

LPAs reviewed medications for R1 and observed R1’s centrally stored medication and destruction record (CSMDR) was not up to date. Medications did not have a physician’s order on file. Staff stated that the medications for R1 were destroyed, however, no written documentation could be provided. At 03:40PM, LPAs observed R1’s PRN Senna Tab 8.6mg at the facility. Staff #3 (S3) stated they kept the medication as they were using it for their stomach pain. Administrator destroyed the medication during the visit.

The following deficiencies were observed (See LIC 809-D) and cited from the California Code of Regulations, Title 22. Civil penalties were issued in the amount of $850 for criminal record clearance ($600) and repeat violation ($250) for CCR section 87465(e) cited on 07/02/2025 regarding physician’s orders to be maintained for medications. Failure to correct the deficiencies may result in additional civil penalties. Exit interview was conducted. A copy of the report and appeal rights were provided.

NAME OF LICENSING PROGRAM MANAGER: Kristin Heffernan
NAME OF LICENSING PROGRAM ANALYST: Angela Barutyan
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/30/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/30/2026
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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Document Has Been Signed on 04/30/2026 05:05 PM - It Cannot Be Edited


Created By: Angela Barutyan On 04/30/2026 at 04:08 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. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: VALLEY VILLAGE SENIOR LIVING, INC.
FACILITY NUMBER: 197610051

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/30/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/01/2026
Section Cited
CCR
87355(e)(3)

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Criminal Record Clearance (e) All individuals subject to a criminal record review...shall prior to working, residing or volunteering in a licensed facility:
(3) Request a transfer of a criminal record clearance...
This requirement is not met as evidenced by:
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Administrator stated he will associate the two staff members by the due date and submit proof to CCLD.
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Based on record review, observation, and interview, the licensee did not comply as two (2) out of three (3) staff members observed at the facility did not have a transfer of criminal record clearance which poses an immediate health and safety risk to persons in care.
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Type A
05/01/2026
Section Cited
CCR87465(e)

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(e) For every prescription and nonprescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician, on a prescription blank, maintained in the residents file...
This requirement is not met as evidenced by:
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Administrator stated he will obtain the written physician's orders residents medications and will provide proof to CCLD by the due date.
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Based on record review and interview, the licensee did not comply with the section cited as Resident #1 (R1)'s medications did not have physician's orders on file which posed an immediate health and safety risk.
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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.
Kristin Heffernan
NAME OF LICENSING PROGRAM MANAGER:
Angela Barutyan
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/30/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/30/2026


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 04/30/2026 05:05 PM - It Cannot Be Edited


Created By: Angela Barutyan On 04/30/2026 at 04:14 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. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: VALLEY VILLAGE SENIOR LIVING, INC.
FACILITY NUMBER: 197610051

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/30/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/01/2026
Section Cited
CCR
87465(h)

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Incidental Medical and Dental Care
(h) The following requirements shall apply to medications which are centrally stored:
This requirement is not met as evidenced by:
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Administrator stated he will audit the CSMDRs for the current residents and will submit a signed statement of understanding of the section cited to CCLD by the due date.
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Based on record review and interview, the licensee did not comply as Resident #1 (R1)'s centrally stored medication and destruction record (CSMDR) was not up to date which poses an immediate health and safety risk to persons in care.
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Type A
05/01/2026
Section Cited
CCR87465(i)

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(i) Prescription medications which are not taken with the resident upon termination of services...shall be destroyed in the facility by the facility administrator and one other adult who is not a resident. Both shall sign a record...
This requirement is not met as evidenced by:
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Administrator destroyed R1's medication during the visit. Administrator will submit a signed statement of understanding including staff signatures to CCLD of the section cited by the due date.
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Based on interview, record review, and observation, the licensee did not comply as R1's medications were not properly destroyed nor documented upon their termination of services which poses an immediate health and safety risk to persons in care.
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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.
Kristin Heffernan
NAME OF LICENSING PROGRAM MANAGER:
Angela Barutyan
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/30/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/30/2026


LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 04/30/2026 05:05 PM - It Cannot Be Edited


Created By: Angela Barutyan On 04/30/2026 at 04:20 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. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: VALLEY VILLAGE SENIOR LIVING, INC.
FACILITY NUMBER: 197610051

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/30/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/07/2026
Section Cited
CCR
87211(a)(1)

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Reporting Requirements (a) Each licensee shall furnish...(1) A written report shall be submitted to the licensing agency...within seven days of the occurrence of any of the events specified in (A) through (D) below...
This requirement is not met as evidenced by:
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Administrator stated he will submit R1's incident and death report to the Department. Administrator will also submit a signed statement of understanding of the section cited to CCLD by the due date.
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Based on record review and observation, the licensee did not comply as incident and death reports for Resident #1 (R1) were not submitted to the Department which poses a potential health and safety risk to persons in care.
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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.
Kristin Heffernan
NAME OF LICENSING PROGRAM MANAGER:
Angela Barutyan
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/30/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/30/2026


LIC809 (FAS) - (06/04)
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