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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610567
Report Date: 02/04/2025
Date Signed: 02/04/2025 01:29:18 PM

Document Has Been Signed on 02/04/2025 01:29 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:SAINT MARIAM SENIOR CAREFACILITY NUMBER:
197610567
ADMINISTRATOR/
DIRECTOR:		MARINA ZHIGOYANFACILITY TYPE:
740
ADDRESS:18228 ACRE STREETTELEPHONE:
(213) 476-2354
CITY:NORTHRIDGESTATE: CAZIP CODE:
91325
CAPACITY: 6CENSUS: 5DATE:
02/04/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:35 AM
MET WITH:Marina Zhigoyan, AdministratorTIME VISIT/
INSPECTION COMPLETED:
01:35 PM
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On 02/04/25, at 9:35am, Licensing Program Analyst (LPA), Gina Saucedo, arrived to conduct an unannounced, annual inspection at the facility. Upon arrival, LPA Saucedo met with Caregiver Diana Lalaianand disclosed the purpose of the visit. The administrator, Marina Zhigoyan was advised of the visit and arrived about forty (40) minutes later.

LPA asked for the census, resident, and staff files.

A physical tour was conducted at 11:30 AM and observed the following: Facility is a single-story home:



The Kitchen area was toured, and LPA observed there to be sufficient seven (7) day supply of non-perishable foods and perishable food for all residents. The kitchen area was clean at the time of the tour. There is one (1) fire extinguisher that is located on your right-hand side of the kitchen against the wall with an expiration date of 03/2025. There is a telephone line on the counter in the kitchen. There is extra, food in the kitchen pantries. The knives are kept in two (2) top drawers of the kitchen counter one (1) on your right-side and one (1) on your left-side in a locked and inaccessible to the residents.

The resident/staff files are be kept in a tall, black cabinet along with the medication/first aid cabinet locked, secured and inaccessible to the residents by the entrance of the facility.

Outside/Backyard: The outside/backyard has furniture for the residents with proper seating. The facility does have a signal system. The facility does not have a pool/body of water. There is no garage.

LIC 809C-continued
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Gina Saucedo
LICENSING EVALUATOR SIGNATURE: DATE: 02/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/04/2025
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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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: SAINT MARIAM SENIOR CARE
FACILITY NUMBER: 197610567
VISIT DATE: 02/04/2025
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Bedrooms: There is a total of four (4) bedrooms and three (3) bathrooms. One (1) of the bedrooms has a private bathroom. Three (3) bedrooms are shared and one (1) bedroom is single occupied. All bedrooms and bathrooms were toured and were properly furnished and have appropriate bedding, linens, toiletry, and lightning. The bathrooms have proper toiletry and grab bars. The bathroom temperatures of the water are within regulations reading at 110-111 degree Fahrenheit. There is three (3) pantries in the hallways that have extra linen.

There is one (1) washer and dryer that is located near the kitchen area and have the chemicals in the above cabinets locked and inaccessible to the residents.

The dining/living room area has enough seating for the residents and the staff with a large television. The furniture is in good condition. There is a fire place that has a black covering inaccessible to the residents. This is where the staff/resident files are kept and the medication cabinet.

The house temperature is at 73-degree Fahrenheit.

The smoke detector/carbon monoxide is in the hallway and is operable.



Administration:

These signs are located at the entrance of the facility: Emergency and Disaster Plan For Residential Care Facilities For The Elderly and Residential Infection plan, Personal Rights of Residents, Rights of Resident by Council, Family Council, Ombudsman, Facility Sketch, Theft and Loss Policy, House Rules, Non-discrimination Policy, Disaster Plan and YES. The insurance expires 04/2025.

An exit interview was conducted, no citation(s) were issued, and a copy of this report was issued.
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Gina Saucedo
LICENSING EVALUATOR SIGNATURE:

DATE: 02/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/04/2025
LIC809 (FAS) - (06/04)
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