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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610306
Report Date: 05/02/2025
Date Signed: 05/02/2025 02:44:27 PM

Document Has Been Signed on 05/02/2025 02:44 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:ASSISTED SENIOR CARE FACILITYFACILITY NUMBER:
197610306
ADMINISTRATOR/
DIRECTOR:		AGHABEKYAN, GAYANEFACILITY TYPE:
740
ADDRESS:7039 CLAIRE AVETELEPHONE:
(818) 578-5958
CITY:RESEDASTATE: CAZIP CODE:
91335
CAPACITY: 6CENSUS: 5DATE:
05/02/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Gayane Aghabekyan, AdministratorTIME VISIT/
INSPECTION COMPLETED:
03:15 PM
NARRATIVE
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At 10:00 AM, Licensing Program Analyst (LPA) Huma Rahimi conducted an unannounced Case Management - Incident visit to this facility and met with staff and the Administrator Gayane Aghabekyan and Administrator Rima Agaronyan were contacted and arrived at the facility shortly after. LPA explained the reason for the visit.
On 04/30/2025, Community Care Licensing Division (CCLD) received an incident report for Resident #1 (R1). It was reported that on 04/28/2025, R1 was noted to have a skin breakdown and the Administrator contacted R1's Primary Physician and R1 was assessed by Kaiser Home Health Registered Nurse(HHRN). The (HHRN) confirmed that R1 has stage 3 pressure ulcer near the buttocks area.
During today's visit, LPA conducted an interview with R1 who informed LPA that two weeks prior to 04/28/2025, the staff #1, Hasmik Yeghiazaryan noticed redness on the buttocks area. R1 also informed LPA that the staff was repositioning R1 each four (4) to five (5) hours daily prior to 04/28/2025. Furthermore, LPA conducted an interview with the Administrator and Administrator Designee and both denied ever been notified from any of the staff that R1 had any redness prior to 04/28/2025. LPA conducted review of R1's facility file, Physician Report dated 04/1/2024, Preplacement Appraisal date on 03/09/2024, Appraisal Needs and Services Plan on 04/30/2025. Admission Agreement date on 03/9/2024.
Review of Physician report revealed that R1 has history of skin condition or breakdown near buttock area and review of Appraisal Needs and Services Plan revealed that page #4 was completed partially, and page #5 was completed only; therefore, no proper assessment was conducted and R1 ended up having stage 3 pressure ulcer as of 04/28/2025. Although R1 currently is receiving wound care through Kaiser home health, the facility failed to submit an exception letter to CCLD in a timely manner. Therefore, deficiencies will be cited on LIC 809D.
Appeal rights explained 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: 05/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/02/2025
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 05/02/2025 02:44 PM - It Cannot Be Edited


Created By: Huma Rahimi On 05/02/2025 at 12:52 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: ASSISTED SENIOR CARE FACILITY
FACILITY NUMBER: 197610306

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/02/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/05/2025
Section Cited
CCR
87611(a)

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87611(a) General Requirements for Allowable Health Conditions (a) Prior to accepting or retaining a resident with an allowable health condition as specified in Section 87618… Section 87631, Healing Wounds; licensees… shall obtain Department approval:
This requirement is not met as evidenced by:
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The Aministrator will submit a written request for an exception for R1's restricted health condition (Pressure Wound Care) by POC due date.
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Based on observation and interview, the licensee did not comply with the section cited above by not obtaining an approval from the department for R1's prohibited health condiction (stage 3 pressure wound) which was discovered on 04/28/25 this poses an immediate health, safety or personal rights risk to persons in care.
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Type A
05/05/2025
Section Cited
CCR87615(a)

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87615(a) Prohibited Health Conditions (a)Persons who require health services for or have a health condition including, but not limited to, those specified below shall not be admitted or retained in a residential care facility for the elderly: (1) Stage 3 and 4 pressure injuries.
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The Administrator has agreed to the following: All staff take state approved training on the regulation Prohibited Health Conditions. Submit training schedule with the vendors name, date of schedule. Upon completion submit the training material and staff sign in sheet.
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Based on record review & interviews the licensee did not comply with the section cited by R1 developing stage 3 ulcers while under the facility care. This poses an immediate health and safety risk to the resident 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.
Nichelle Gillyard
NAME OF LICENSING PROGRAM MANAGER:
Huma Rahimi
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/02/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/02/2025


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 05/02/2025 02:44 PM - It Cannot Be Edited


Created By: Huma Rahimi On 05/02/2025 at 12:59 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: ASSISTED SENIOR CARE FACILITY
FACILITY NUMBER: 197610306

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/02/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/09/2025
Section Cited
CCR
87464(f)(1)

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Basic Service: (f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c).
This requirement is not met as evidenced by:
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 Administrators will schedule 2 hours vendorized training for themselves and all staff related to the cited section.
1) Verification of the scheduled training with the credentials of the trainer will need to be emailed to the LPA by POC due date.
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Based on interviews and record reviews the licensee failed to provide care and supervision to R1 who developed stage 3 ulcers residing at the facility which poses a potential health and safety risk to residents in care.
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Type B
05/09/2025
Section Cited
CCR87412(c)(2)(A-D)

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Personnel Records:
(c) Licensees shall maintain in the personnel records verification of required staff training and orientation. (2) Documentation of staff training shall include:
This requirement is not met as evidenced by:
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The Administrator shall submit proof that all staff will complete "in service" trainings. The Administrator shall submit proof to LPA by POC due date. Additionally, submit a complete body check forms for each resident for the next two week.
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Based on interviews and record review the licensee did not comply by not making sure all trained staff followed the "in service" training knowledge and conducted daily body checks on R1 for the history of skin breakdown which poses a potential health and safety risk to residents 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.
Nichelle Gillyard
NAME OF LICENSING PROGRAM MANAGER:
Huma Rahimi
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/02/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/02/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/02/2025 02:44 PM - It Cannot Be Edited


Created By: Huma Rahimi On 05/02/2025 at 01:53 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: ASSISTED SENIOR CARE FACILITY
FACILITY NUMBER: 197610306

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/02/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/09/2025
Section Cited
CCR
87463(a)

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Reappraisals: (a) The pre-admission appraisal shall be updated, in writing as frequently as necessary....... the appraisal accurate. The reappraisals shall document changes in the resident's physical, medical...
This requirement is not met as evidenced by:
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Administrator agreed to submit a statement of understanding on how all residents will have a proper reappraisal when changes occur to ensure their needs are met. Additionally, the Administrator will properly complete the reappraisal for R1 and submit to LPA by POC date.
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Based on interview and record reviews, licensee did not comply with the section cited above. Administrator completed partial reappraisals for R1 on 04/30/2025 upon observing the stage 3 ulcer on R1's buttocks area, which poses/posed a potential health and safety risk to resident 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.
Nichelle Gillyard
NAME OF LICENSING PROGRAM MANAGER:
Huma Rahimi
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/02/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/02/2025


LIC809 (FAS) - (06/04)
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