197610412-8-29-2025-31-AS-NSHN-DKZT9Z-20250829143245

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610412
Report Date: 08/29/2025
Date Signed: 08/29/2025 02:32:54 PM

Document Has Been Signed on 08/29/2025 02:32 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:	GRANT SERENITY OF VERDUGO, INC.		FACILITY NUMBER:	197610412
ADMINISTRATOR/ DIRECTOR:	NORAYR BADALYAN		FACILITY TYPE:	740
ADDRESS:	3214 W. VERDUGO AVE		TELEPHONE:	(818) 433-7073
CITY:	BURBANK	STATE: CA	ZIP CODE:	91505
CAPACITY: 6		CENSUS: 5	DATE:	08/29/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:00 AM
MET WITH:	Diana Castellanos-Administrator		TIME VISIT/ INSPECTION COMPLETED:	02:30 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Nadia Shahbazian conducted an Annual Required visit and inspection of the facility. LPA met with Administrator Diana Castellanos and explained the reason for the visit. Facility is licensed to serve 6 non-ambulatory residents over the age of 60, of which (3) may be bedridden, with a hospice waiver for (2). Current census is 5 residents, (1) of which is receiving hospice services. Facility has a valid Certificate of Liability Insurance, with expiration date of 05/20/2026. At 9:45am, with the assistance of administrator, LPA took a tour of the physical plant. Required postings were observed in the entry area. The auditory alarms on all exit doors were installed and functional at the time of the visit. The smoke/carbon monoxide detectors are hardwired and interconnected. At 10:10 am the smoke/carbon monoxide detectors were tested and observed to function properly. The are two fire extinguishers, one in the laundry room and one in the hallway. Both fire extinguishers are full with a charge date of 04/27/2025. Facility conducts quarterly emergency drills. The last fire and earthquake drill was conducted together on 07/07/2025. Facility uses the front entry door as the main exit. There is an additional exit door on the hallway next to bedroom #1 and another exit door in the laundry room. There is a side gate, in the front, for emergencies as well. Kitchen: The kitchen appliances include a refrigerator, stove/oven and microwave; all fixtures were functional. LPA found a sufficient supply of perishable (2 days) and non-perishable (7 days) foods at the facility. Knives were stored in a locked drawer in the kitchen and detergents/chemicals were stored locked, underneath the sink. All kitchen surfaces and cabinets were observed to be clean and sanitary. Common Areas: These included the living room and dining area. The living room was furnished with sofas, a television set and a cabinet for storage of games. Dining room was furnished with a dining table and six chairs, appropriate for number of residents. Continued on 809-C

NAME OF LICENSING PROGRAM MANAGER: Eva Miller
NAME OF LICENSING PROGRAM ANALYST: Nadia Shahbazian
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 08/29/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2025

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 S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: GRANT SERENITY OF VERDUGO, INC.	FACILITY NUMBER: 197610412
	VISIT DATE: 08/29/2025

NARRATIVE

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Bedrooms: There are five (5) bedrooms designated for residents' use. Bedroom #1 and #2 are designated for bedridden residens. All bedrooms are were properly furnished with appropriate beddings, chairs, cabinets, linens and have sufficient lighting.

Bathrooms: There are two (2) bathrooms, one for staff use and one for residents' use. LPA observed functional fixtures, grab bars and non-skid mats in each bathroom. Hot water temperature in resident bathroom was measured at 115.4 degrees Fahrenheit.

Surrounding Grounds: There were no pool but there is a tall water fountain, against the back wall of the backyard. Surrounding areas were clean, sanitrary and clear of obstructions. There is a covered patio with furniture appropriate for outdoor use. There is a side gate for emergencies and there is a detached garage, currently used as storage. LPA observed a refrigerator, with supply of perishable foods in the garage. Facility has a power generator and is equipped with visual cameras throughout the front yard, back yard and common areas. In addition facility has internet, cable and telephone lines for resident's use.

Laundry Room: The laundry room is located near the kitchen and has an exit door, leading to the backyard. Both washer and dryers are functional; the chemicals and detergents are kept locked in cabinets. In addition there is a cabinet for emergency food and a supply of non-perishable food items. LPA observed three cans of vegetables with expiration date of 05/07/2025. Administrator immediately removed and trashed the cans. A citation will be issued for the expired food supply.

Resident Files/Medications: Resident files for all five residents were reviewed to ensure compliance with required documentation. Medications for 3 out of 5 residents for counted for accuracy of administration.

Office Area: Office is located near bedroom #1. LPA observed resident and staff files locked in the office area. The medications were kept locked in cabinets and in a locked refrigerator in the office. A complete first aid kit and the first aid manual were also kept in the office.

Staff Files: LPA also conducted a file review of records for 4 staff, to insure forms and training are up to date and in compliance with licensing requirements.

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

Exit interview conducted and copy of this report was provided to the administrator.

NAME OF LICENSING PROGRAM MANAGER: Eva Miller
NAME OF LICENSING PROGRAM ANALYST: Nadia Shahbazian
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 08/29/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 08/29/2025 02:32 PM - It Cannot Be Edited

Created By: Nadia Shahbazian On 08/29/2025 at 02:23 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: GRANT SERENITY OF VERDUGO, INC.	FACILITY NUMBER: 197610412
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/29/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87555(b)(8)

(b) The following food service requirements shall apply: (8) All food shall be of good quality. Food in damaged or expired containers shall not be accepted, used or retained. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above. 3 cans of vegetables with expiration date of 05/07/2025 were observed in a locked storage cabinet in the laundry room, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/29/2025
	Plan of Correction
1 2 3 4	Administrator immediately removed and trashed the three cans of vegetables. Administrator will ensure that all food supplies are clearly marked and dated and will also ensure that staff will review expiration dates to ensure food health and safety.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Eva Miller
NAME OF LICENSING PROGRAM MANAGER:

	Nadia Shahbazian
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/29/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2025

LIC809 (FAS) - (06/04)

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