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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610695
Report Date: 02/25/2025
Date Signed: 02/25/2025 12:32:50 PM

Document Has Been Signed on 02/25/2025 12:32 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:ACTON SENIOR HOUSING CARE, INCFACILITY NUMBER:
197610695
ADMINISTRATOR/
DIRECTOR:		KHACHATRYANFACILITY TYPE:
740
ADDRESS:31511 INDIAN OAK ROADTELEPHONE:
(909) 550-9309
CITY:ACTONSTATE: CAZIP CODE:
93510
CAPACITY: 6CENSUS: 0DATE:
02/25/2025
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:45 AM
MET WITH:Hasmik KhachatryanTIME VISIT/
INSPECTION COMPLETED:
12:45 PM
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On 02/25/2025 at 09:45 am, Licensing Program Analyst (LPA) Lorena Casillas conducted an announced Pre-Licensing Inspection with Licensee Suren Galstyan and Administrator Hasmik Kachatryan. An application to operate a Residential Care Facility for the Elderly (RCFE) was received by Community Care Licensing (CCL) on 09/03/2024. A fire clearance was approved on 10/25/2024, for five (5) non-ambulatory residents and one (1) bed ridden resident for a total capacity of six (6). The purpose of today’s visit is to inspect the facility to ensure that it maintains compliance under California Code of Regulations, Title 22, Division 6.

The Component III presentation was conducted from 10:05 am until 11:35 am with Licensee and Administrator.

A tour of the physical plant was initiated at approximately 11:45 am and the following was observed:

The facility maintains a comfortable temperature of 78 degrees F.

KITCHEN: The facility has a Kitchen area that is equipped with a refrigerator, microwave oven and sink. There was an adequate supply of nonperishable food and dining ware to accommodate a maximum capacity of six (6). Perishable food will be purchased once residents are established. Knives will be locked in a kitchen drawer.

BEDROOMS: The facility has a total of four (4) bedrooms of which three (3) are for resident use and one (1) bedroom for staff use. Bedrooms #1 through #3 are designated for two (2) non ambulatory residents each. Bedroom #3 can be used for one (1) bedridden resident. The applicant furnished the resident bedrooms with beds, nightstand, chairs, dresser, bedding and linens. All rooms had sufficient lighting.

Continued on LIC809-C
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Lorena Casillas
LICENSING EVALUATOR SIGNATURE: DATE: 02/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/25/2025
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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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: ACTON SENIOR HOUSING CARE, INC
FACILITY NUMBER: 197610695
VISIT DATE: 02/25/2025
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BATHROOMS: The facility has three (3) bathrooms. All bathrooms were observed to have the proper fixtures, and non-skid mats. The hot water delivered in the bathrooms measured 119.6 degrees F.

COMMON AREAS: These included the living room and dining room areas, which were equipped with living room furniture, a television, tables, and chairs. The dining room table is large enough to accommodate up to six (6) residents. There were no visible immediate hazards. The smoke alarms are hard wired, inter-connected and are a combination with carbon monoxide. The facility has two (2) fire extinguishers that were purchased on 11/25/2024 and are fully charged. One is located in the kitchen and one in a hallway.



LAUNDRY ROOM: Laundry room is adjacent to the staff bedroom and has washer and dryer. Cleaning detergents and supplies are locked in the laundry room.

MEDICATIONS: Medications and first aid kit will be stored in a locked cabinet in the kitchen area.

GARAGE: The garage is used for additional storage.

STAFF/RESIDENT RECORDS: Staff and resident records will be stored in a locked cabinet, located in the living room. The applicant was advised to ensure that resident and staff records will be accessible to the licensing agency upon request or during inspection.

SURROUNDING GROUNDS: The driveway, passageways and entrance to the home was clear of obstruction. The backyard of the facility has a patio and backyard furniture. The facility backyard has sufficient yard space to accommodate outdoor activities. There is no swimming pool or bodies of water.

No deficiencies noted. Exit Interview was conducted, and a copy of this report was given to Administrator.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Lorena Casillas
LICENSING EVALUATOR SIGNATURE:

DATE: 02/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/25/2025
LIC809 (FAS) - (06/04)
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