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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610657
Report Date: 11/03/2025
Date Signed: 11/03/2025 03:57:29 PM

Document Has Been Signed on 11/03/2025 03:57 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:G & A BOARDING CAREFACILITY NUMBER:
197610657
ADMINISTRATOR/
DIRECTOR:		SHAMAMYAN, GRIGORFACILITY TYPE:
740
ADDRESS:7001 GARDEN GROVE AVENUETELEPHONE:
(818) 359-7379
CITY:RESEDASTATE: CAZIP CODE:
91335
CAPACITY: 6CENSUS: 5DATE:
11/03/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Grigor Shamamyan, AdministratorTIME VISIT/
INSPECTION COMPLETED:
04:20 PM
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At 09:30 AM, Licensing Program Analyst (LPA), Huma Rahimi conducted an unannounced annual visit to the above facility and met with the staff #1 (S1) Lina Teprjian and the Administrator Gregor Greg Shamamyan, was contacted via telephone. LPA explained the reason for the visit. Administrator arrived shortly after.

The facility is cleared for five (5) Non-ambulatory, and one (1) Bedridden (room #4) residents. The facility is a single-story building with four (4) bedrooms and two bathrooms for residents use. During today's site visit LPA and S1 toured the facility inside and out and observed the following:

KITCHEN: The kitchen area that is equipped with a refrigerator, microwave oven, and a sink. Stove was observed in a good working condition. At 09:35am, LPA observed adequate supplies of perishable and nonperishable food and dining ware to accommodate a maximum capacity of six (6). All knives were observed in a kitchen drawer and were locked and inaccessible to residents in care. LPA observed a Fire Extinguisher on the kitchen wall and was last purchased on 11/03/2025.

MEDICATION ROOM: The centrally stored medication are observed in the kitchen cabinet and were locked and inaccessible to residents in care. LPA observed medications in two (2) residents rooms unlocked and accessible to residents in care. Additionally, LPA observed staff medication accessible in the kitchen in a separate cabinet. Moreover, LPA observed staff and residents medications unlocked and accessible in the facility's fridge. During review of R3's random medication revealed that the facility was supposed to start Januvia 100 MG (Diabetes Medication) a new bottle on 10/08/2025.


Continue on LIC 809C
NAME OF LICENSING PROGRAM MANAGER: Nichelle Gillyard
NAME OF LICENSING PROGRAM ANALYST: Huma Rahimi
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 11/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/03/2025
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: G & A BOARDING CARE
FACILITY NUMBER: 197610657
VISIT DATE: 11/03/2025
NARRATIVE
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During today's visit LPA counted R3's medication and it was discovered that there was a discrepancy and five (5) extra pills were in the bottle. LPA asked the Administrator and the staff for explaining and both staff and the Administrator could not provide any answers.

BEDROOMS: There are four (4) bedrooms designated for resident’s use. LPA observed that all bedrooms are furnished with beds, dressers and required bedding and linen. The bedrooms have sufficient closet space and have sufficient lighting. Auditory alarms were tested and observed to be operational.

BATHROOMS: LPA observed that the facility has two (2) bathrooms. LPA observed all bathrooms are clean and in good repair. Properly supplied with toilet papers, soap and paper towels. LPA observed appropriate grab bar and had non-skid mat. The water temperature was noted at 111.6°.

LAUNDRY ROOM: The laundry room is located by the kitchen in a closet where all cleaning supplies and laundry detergents are kept. LPA observed that the laundry room was locked and inaccessible to residents in care. All cleaning supplies and laundry detergents are kept in the laundry closet. The washer/dryer appear to be in good working condition.

COMMON AREAS: The facility maintains a comfortable temperature at 71°F. The living room and dining area
appeared clean and were properly furnished and has a television. No obstructions and or tripping hazards throughout the facility. LPA observed a working telephone for the facility.

SURROUNDING GROUNDS: The facility has sufficient front yard space. LPA did observe appropriate outdoor furniture in the backyard of the facility that can accommodate six (6) residents, LPA observe a covered shaded area for residents with some games for outdoor activities. There is no swimming pool or any bodies of water at the facility. LPA observed one emergency exit and it was observed free of any obstruction or hazard.

Garage/Storage: The facility does not have any extra garage/storage space.

Continue on LIC 809C

NAME OF LICENSING PROGRAM MANAGER: Nichelle Gillyard
NAME OF LICENSING PROGRAM ANALYST: Huma Rahimi
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 11/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2025
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: G & A BOARDING CARE
FACILITY NUMBER: 197610657
VISIT DATE: 11/03/2025
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SMOKE DETECTORS/CARBON MONOXIDE. Smoke detectors and carbon monoxide were located throughout the facility. At 1:00 PM, they were tested and observed to be operational.

Between 12:00 PM to 2:45 PM, LPA reviewed records of five (5) residents and one (1) staff. Two (2) out of five (5) residents did not have TB test results. S1 did not have any of the required training on file.

During the visit, LPA observed two staff working providing care and supervision to residents in care; however, both staff (S1 and S2) were not fingerprint cleared and associated to the facility. S2 hire date was 09/24/2025, and S2 only worked at the facility for four (4) days since hire date.

Administrative: LPA collected Certificate of Liability Insurance, and LIC500.

Deficiencies issued on LIC 809D.

Exit interview conducted. Appeal rights explained and 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: 11/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2025
LIC809 (FAS) - (06/04)
Page: 4 of 7
Document Has Been Signed on 11/03/2025 03:57 PM - It Cannot Be Edited


Created By: Huma Rahimi On 11/03/2025 at 02:24 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: G & A BOARDING CARE
FACILITY NUMBER: 197610657

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/03/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87458(c)(1)(A)
Medical Assessment
(c) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the licensed medical professional's diagnosis or diagnoses and results of an examination for all of the following: (A) Communicable tuberculosis.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in two (2) out of five (5) residents (R1 & R5) did not have any TB test results on file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/10/2025
Plan of Correction
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Administrator Agreed to contact R1's and R5's Physician and do a TB test by 11/10/2025. The proof will be provided to LPA by POC due date.
Type B
Section Cited
CCR
87465(h)(2)
87465(h)(2) Incidental Medical and Dental Care- Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA’s observation, the licensee failed to ensure that the facility's medication was locked and inaccessible to residents in care. This posed a potential health risk to residents in care
POC Due Date: 11/10/2025
Plan of Correction
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All staff will complete in-service training regarding access policy to medications by the POC due date. Licensee will provide statement that moving forward, medication locking mechanism will comply with regulations. Evidence of completion to be submitted to LPA as POC.
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: 11/03/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/03/2025


LIC809 (FAS) - (06/04)
Page: 5 of 7
Document Has Been Signed on 11/03/2025 03:57 PM - It Cannot Be Edited


Created By: Huma Rahimi On 11/03/2025 at 02:36 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: G & A BOARDING CARE
FACILITY NUMBER: 197610657

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/03/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
7355(e)(1)

7355(e)(1) Criminal record clearance: (e) All individuals subject to a criminal record review... (1) Obtain a California clearance or a criminal record exemption as required by the Department.
This requirement is not met as evidenced by:

Deficient Practice Statement
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Licensee agreed to complete S1's and S2's fingerprints and associate both staff to the facility. Copy of proof will be submitted to LPA by POC date.
Civil penalty assessed.
POC Due Date: 11/05/2025
Plan of Correction
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Based on interview and record review, the licensee did not comply with the section cited above by hiring S1 on 11/01/2024 S2 on 09/24/2025 without fingerprint clearance, which poses an immediate health, safety or personal rights risk to persons in care.
Type A
Section Cited
CCR
87465(c)(2)
87465- Incidental Medical and Dental Care:
c) If the resident's physician has stated in writing... 2) Once ordered by the physician the medication is given according to the physician's directions.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on (observation) (interview) (record review)], the licensee did not comply with the section cited above in
not assuring that R3's prescribed medications were given as prescribed, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/05/2025
Plan of Correction
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Administrator agreed to schedule vendorized training for all staff by 11/05/2025 and submit to CCL the vendor information and scheduled date of training. Training certifications to be submitted to CCL upon completion. Administrator also agreed to notify doctor and submit LIC 624 to CCL regarding the incident.
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: 11/03/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/03/2025


LIC809 (FAS) - (06/04)
Page: 6 of 7
Document Has Been Signed on 11/03/2025 03:57 PM - It Cannot Be Edited


Created By: Huma Rahimi On 11/03/2025 at 03:11 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: G & A BOARDING CARE
FACILITY NUMBER: 197610657

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/03/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.625(b)(1)
Staff Training: (b) (1)(2).... This training shall consist of 40 hrs; 20 hrs, including six hrs specific to dementia care...and four hrs specific to .... before working independently with residents; remaining 20 hours shall include six hours specific to dementia...shall be completed within the first four weeks of employment. This requirement is not met as evidence by:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on the record review and interview, the licensee failed to comply with the section cited above by not providing any required training to S1 which poses a potential health risks to residents in care.
POC Due Date: 11/10/2025
Plan of Correction
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Licensee/Administrator agreed to have staff complete the required training hours according to the health and safety code referenced and submit proof of training record to LPA by 11/10/2025.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: 11/03/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/03/2025


LIC809 (FAS) - (06/04)
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