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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610177
Report Date: 06/18/2025
Date Signed: 06/18/2025 04:01:36 PM

Document Has Been Signed on 06/18/2025 04:01 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:ANNA'S HOME & PARADISEFACILITY NUMBER:
197610177
ADMINISTRATOR/
DIRECTOR:		ARMENYAN, ANNAFACILITY TYPE:
740
ADDRESS:23463 HAYNES STTELEPHONE:
(323) 660-0001
CITY:WEST HILLSSTATE: CAZIP CODE:
91307
CAPACITY: 6CENSUS: 5DATE:
06/18/2025
TYPE OF VISIT:OfficeUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:30 PM
MET WITH:Anna ArmenyanTIME VISIT/
INSPECTION COMPLETED:
04:00 PM
NARRATIVE
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At approximately 1:30 p.m. on 06/18/25 Licensing Program Analyst (LPA) Nicholas Reed initiated an unannounced case management visit at the Woodland Hills-South Regional Office. LPA met with the licensee and disclosed the reason for the visit.

The purpose of today’s case management visit was to issue deficiencies previously noted at the facility during complaint investigations on 06/05/25 and 06/17/25 of complaints # 31-AS-20250602111246 and # 31-AS-20250616164325. During the investigations, LPA requested records for all residents. Record review at 10:30 a.m. on 06/17/25 revealed that Resident #1 (R1) was admitted without a medical assessment within the past twelve (12) months.

R1 also did not have a preplacement appraisal, admission agreement, care plan. inventory list, or signed personal rights form. R1 was admitted with a G-tube and a catheter and was receiving hospice services, yet the licensee admitted at 1:20 p.m. on 06/18/25 that the facility did not retain R1’s hospice paperwork. R1 was readmitted to the facility around 06/11/25 with a Total Parenteral Nutrition (TPN) line and a catheter but no home health services or documents.

Resident #2 (R2) had a medical assessment which was older than twelve (12) months.

The facility did not update the care plan for Resident #3 (R3) within the past twelve (12) months.

Resident #4 (R4) signed up for a private room in their admission agreement. R4 also did not have signed consent forms, tuberculosis results, inventory sheet, or signed personal rights form. Around 10:00 a.m. on 06/17/25 and at 1:00 p.m. on 06/05/25, LPA observed R4 was in a shared room with R3. Additionally, R3 and R4 both noted that they did not enjoy living with one another in the same room.

NAME OF LICENSING PROGRAM MANAGER: Naira Margaryan
NAME OF LICENSING PROGRAM ANALYST: Nicholas Reed
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 06/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/18/2025
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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Document Has Been Signed on 06/18/2025 04:01 PM - It Cannot Be Edited


Created By: Nicholas Reed On 06/18/2025 at 01:20 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., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: ANNA'S HOME & PARADISE
FACILITY NUMBER: 197610177

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/18/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/03/2025
Section Cited
CCR
87457(c)

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87457 Pre-Admission Appraisal (a) Prior to admission, the prospective resident... shall be interviewed by the licensee... (c)... a determination of the prospective resident's suitability for admission shall be completed. This requirement was not met as evidenced by:
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Licensee to submit a written statement that all resident records, including but not limited to, medical assessments, appraisals, care plans, consent forms, and admission agreements, will be reviewed and completed.
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Based on record review, the licensee did not comply with the section cited above through not documenting a preplacement for Resident #1 (R1) which posed a potential risk to the Health, Safety, or Personal Rights of persons in care.
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Type B
07/03/2025
Section Cited
CCR87505

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87505 Documentation and Support - Each facility shall document in writing the findings of the pre-admission appraisal and any reappraisal or assessment which was necessary. This requirement was not met as evidenced by:
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Licensee to submit a written statement that all resident records, including but not limited to, medical assessments, appraisals, care plans, consent forms, and admission agreements, will be reviewed and completed.
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Based on record review, the licensee did not comply with the section cited above through not updating the reappraisal for Resident #3 (R3) within twelve months which posed a potential risk to the Health, Safety, or Personal Rights of 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.
Naira Margaryan
NAME OF LICENSING PROGRAM MANAGER:
Nicholas Reed
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/18/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/18/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/18/2025 04:01 PM - It Cannot Be Edited


Created By: Nicholas Reed On 06/18/2025 at 01:40 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: ANNA'S HOME & PARADISE
FACILITY NUMBER: 197610177

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/18/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/03/2025
Section Cited
CCR
87507

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87507 Admission Agreements (a) The licensee shall complete an individual written admission agreement, as defined in Section 87101(a), with each resident or the resident's representative, if any.
This requirement was not met as evidenced by:
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Licensee to submit a written statement that all resident records, including but not limited to, medical assessments, appraisals, care plans, consent forms, and admission agreements, will be reviewed and completed.
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Based on record review, the licensee did not comply with the section cited above through not comlpeting an admission agreement for Resident #1 (R1) which posed a potential risk to the Health, Safety, or Personal Rights of persons in care.
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Type B
07/03/2025
Section Cited
CCR87467(a)

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87467 Resident Participation in Decisionmaking (a) Prior to, or within two weeks of the resident’s admission, the licensee shall arrange a meeting... to prepare a written record of the care the resident will receive in the facility. This requirement was not met as evidenced by:
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Licensee to submit a written statement that all resident records, including but not limited to, medical assessments, appraisals, care plans, consent forms, and admission agreements, will be reviewed and completed.
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Based on record review, the licensee did not comply with the section cited above through not comlpeting a care plan for Resident #1 (R1) which posed a potential risk to the Health, Safety, or Personal Rights of 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.
Naira Margaryan
NAME OF LICENSING PROGRAM MANAGER:
Nicholas Reed
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/18/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/18/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/18/2025 04:01 PM - It Cannot Be Edited


Created By: Nicholas Reed On 06/18/2025 at 02:21 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: ANNA'S HOME & PARADISE
FACILITY NUMBER: 197610177

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/18/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/20/2025
Section Cited
CCR
87458(a)(1)(A)

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87458 Medical Assessment (a) Prior to a person's acceptance as a resident, the licensee shall obtain... (1) A physical examination... and results of an examination for...: (A) Communicable tuberculosis.
This requirement was not met as evidenced by:
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Licensee to take R2 to get tested for tuberculosis and submit a copy of the results.
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Based on record review, the licensee did not comply with the section cited above through not documenting a preplacement for Resident #1 (R2
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Type A
06/20/2025
Section Cited
CCR87633(b)

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87633 Hospice Care of Terminally Ill Residents (b) A current and complete hospice care plan shall be maintained in the facility for each hospice resident.
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Licensee to obtain hospice paperwork for R1 and submit all documents to LPA by POC due date.
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Based on record review, the licensee did not comply with the section cited above through not maintaining a hospice care plan for Resident #1 (R1) which posed a potential risk to the Health, Safety, or Personal Rights of 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.
Naira Margaryan
NAME OF LICENSING PROGRAM MANAGER:
Nicholas Reed
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/18/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/18/2025


LIC809 (FAS) - (06/04)
Page: 5 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.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: ANNA'S HOME & PARADISE
FACILITY NUMBER: 197610177
VISIT DATE: 06/18/2025
NARRATIVE
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Licensee to submit a written statement that all resident records, including but not limited to, medical assessments, appraisals, care plans, consent forms, and admission agreements, will be reviewed and completed.


In lieu of all deficiencies cited on this report, the administrator demonstrated a lack of ability to provide appropriate care and supervision for residents.

Deficiencies are assessed on the corresponding LIC 809-D page.

Exit interview conducted. Appeal rights discussed. Copy of report provided.
NAME OF LICENSING PROGRAM MANAGER: Naira Margaryan
NAME OF LICENSING PROGRAM ANALYST: Nicholas Reed
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2025
LIC809 (FAS) - (06/04)
Page: 6 of 7
Document Has Been Signed on 06/18/2025 04:01 PM - It Cannot Be Edited


Created By: Nicholas Reed On 06/18/2025 at 03:29 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: ANNA'S HOME & PARADISE
FACILITY NUMBER: 197610177

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/18/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/03/2025
Section Cited
CCR
87405

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87405 Administrator - Qualifications and Duties (d) The administrator shall have the qualifications… for… (1) Knowledge of the requirements for providing care and supervision appropriate to the residents. This requirement was not met as evidenced by:
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Licensee to find an accredited vendor for administrator training and to show proof of an appointment by the POC due date.
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Based on record review, the licensee did not comply with the section cited above through providing insufficient care and supervision which posed a potential risk to the Health, Safety, or Personal Rights of 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.
Naira Margaryan
NAME OF LICENSING PROGRAM MANAGER:
Nicholas Reed
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/18/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/18/2025


LIC809 (FAS) - (06/04)
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