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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610547
Report Date: 03/25/2025
Date Signed: 03/26/2025 03:15:10 PM

Document Has Been Signed on 03/26/2025 03:15 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:1ST CLASS BOARD AND CAREFACILITY NUMBER:
197610547
ADMINISTRATOR/
DIRECTOR:		SAAKIAN, ANNAFACILITY TYPE:
740
ADDRESS:9524 ENCINO AVETELEPHONE:
(323) 408-9600
CITY:NORTHRIDGESTATE: CAZIP CODE:
91325
CAPACITY: 6CENSUS: 4DATE:
03/25/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:40 AM
MET WITH:Anna Saakian, AdministratorTIME VISIT/
INSPECTION COMPLETED:
01:45 PM
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On 03/25/2025 at 9:40 AM, Licensing Program Analyst (LPA) Gina Saucedo conducted an unannounced, Annual Inspection and met with Caregiver, Svetlana Vassyyunina. The administrator was called and arrived about fifteen (15) minutes later.

LPA asked for the census, staff and resident files. The physical plant was toured inside and out at 10:50 am.

Living/Dining Room Area: LPA observed the living room furniture to be clean and in good repair. The facility maintains a comfortable temperature at 74 degrees Fahrenheit with a large television. The living room has a fire place that has a black covering.

Bedrooms and Bathrooms: There are five (5) bedrooms. There are two (2) bedrooms that are currently vacant. LPA observed rooms to have bedding sheets, pillowcases, blankets, night stands, televisions, and sufficient lighting for each of the resident’s room. There are three (3) bedrooms that are occupied. One (1) bedroom is shared and has a private bathroom. The other (2) bedrooms are currently privately occupied. There are two (2) other bathrooms. One (1) in the hallway in between the bedrooms and one (1) by the washer and dryer next to the garage. The hot water temperatures in the bathrooms were measured and were within regulations of 116-119 degrees. The showers have non-slip bath mats and grab bars. There is a linen closet in between the bedrooms.

Medications: The medication is kept in the kitchen area in a cabinet locked and inaccessible to the residents along with the first aid and centrally stored medication files.

NAME OF LICENSING PROGRAM MANAGER: Troy Agard
NAME OF LICENSING PROGRAM ANALYST: Gina Saucedo
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 03/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/25/2025
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: 1ST CLASS BOARD AND CARE
FACILITY NUMBER: 197610547
VISIT DATE: 03/25/2025
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There is also a signal system in the facility. The residents are able to ring for assistance if needed. There is one (1) fire extinguisher fully charged and expires on April-2025. It is located in the kitchen.

Kitchen Area: LPA inspected the kitchen area. There are two (2) refrigerators which were clean and LPA observed sufficient supply of seven (7) day non-perishable and perishable foods in the cabinets.

The knives/sharps are kept in the kitchen area on your left-hand side, inaccessible to the residents.

The chemicals are located where the washer and dryer are kept and is locked and inaccessible to the residents. There are several phones located throughout the house.

Outside: LPA toured the outside area. LPA observed a covered shaded area for residents and appropriate outdoor furniture. The facility has a pool which is fenced and locked inaccessible to the residents. There is a family room attached to the house which is on the fire clearance and is only be used for staff not residents.

There is a garage that can be accessed from the entrance of the facility from the kitchen area. There are supplies in the garage area.

The carbon monoxide and the smoke detector were tested, and they were operable, interconnected.

Administration: The Liability Insurance was reviewed and will be renewed on 06/2025. The facility has an Emergency and Disaster Plan For Residential Care Facilities For The Elderly and Infection plan. These signs are located in the back of the facility: Personal Rights of Residents, Rights of Resident Council, Family Council, Infection Control, Emergency and Disaster Plan, Theft and Loss Policy, the facility sketch is located throughout the house. The YES sign and Ombudsman sign are located at the entrance of the facility.

An exit interview was conducted, no citation(s) were issued, and a copy of this report was given to the administrator.

NAME OF LICENSING PROGRAM MANAGER: Troy Agard
NAME OF LICENSING PROGRAM ANALYST: Gina Saucedo
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/25/2025
LIC809 (FAS) - (06/04)
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