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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610735
Report Date: 11/06/2025
Date Signed: 11/06/2025 02:50:54 PM

Document Has Been Signed on 11/06/2025 02:50 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:SUNNY SENIOR CAREFACILITY NUMBER:
197610735
ADMINISTRATOR/
DIRECTOR:		HAYRAPETYAN, VIKTORYAFACILITY TYPE:
740
ADDRESS:18915 LEDAN STREETTELEPHONE:
(818) 394-9029
CITY:NORTHRIDGESTATE: CAZIP CODE:
91324
CAPACITY: 6CENSUS: 5DATE:
11/06/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:50 PM
MET WITH:Ani Tigranyan- Staff TIME VISIT/
INSPECTION COMPLETED:
03:00 PM
NARRATIVE
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In conjunction with the complaint number 31-AS-20251028093801, Licensing Program Analyst (LPA) Mariana Agban conducted a case management- Deficiencies visit. During the complaint investigation, it was confirmed that no physical file existed for Resident #1 (R1) at the facility. Interview with Staff #1 (S1) revealed that R1 was admitted to the facility on or around November 1, 2025, and remained for a few hours before being transferred to the hospital. Additionally, LPA observed that Room #3 was vacant. During the interview with S1, S1 indicated that Resident #2 (R2) is currently hospitalized. LPA conducted a record review and noted that no Special Incident Report (SIR) had been submitted to Community Care Licensing (CCL). Furthermore, it was discovered that the facility has not had a certified administrator since June 6, 2025. LPA also detected the smell of cigarette smoke during the physical plant tour. When asked, S1 denied smoking and stated that the odor was from a neighbor. Subsequently, a pack of cigarettes and a lighter were found in the kitchen. Moreover, LPA requested the LIC 500 – Personnel Report. S1 stated that only she and one other staff member live and work at the facility; therefore, no employee schedule is in place.

Exit interview was conducted, citations were issued, appeal rights were provided, and a copy of this report was signed and delivered.

NAME OF LICENSING PROGRAM MANAGER: Nichelle Gillyard
NAME OF LICENSING PROGRAM ANALYST: Mariana Agban
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 11/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/06/2025
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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Document Has Been Signed on 11/06/2025 02:50 PM - It Cannot Be Edited


Created By: Mariana Agban On 11/06/2025 at 01:35 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: SUNNY SENIOR CARE
FACILITY NUMBER: 197610735

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/06/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/13/2025
Section Cited
CCR
87506(a)

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(a)The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility .. available to facility staff and to licensing agency staff.
This requirement was not met as evidence by:
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Licensee will conduct in service training reviewing this section of the regulation. Licensee will provide all training materials and signatures of all staff that have attended the training by the POC due date.
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Based on information obtained, the Licensee did not comply with the section cited above. There was no physical file existed for Resident #1 (R1) at the facility. This poses a potential health and safety risk to clients in care.
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Type B
11/13/2025
Section Cited
CCR87211(a)(1)

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(1)A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below...
This requirement was not met as evidence by:
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Licenee agreed to provide Special Incident Report (SIR) for R2's hospitalization by the POC date.
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Based on information obtained, the Licensee did not comply with the section cited above. Licensee did not submit SIR regarding Resident#2(R2) hospitalization. This poses a potential health and safety risk to clients in care.
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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:
Mariana Agban
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 11/06/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/06/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/06/2025 02:50 PM - It Cannot Be Edited


Created By: Mariana Agban On 11/06/2025 at 01:49 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: SUNNY SENIOR CARE
FACILITY NUMBER: 197610735

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/06/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/27/2025
Section Cited
CCR
87405(a)

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Administrator - Qualifications and Duties (a) All facilities shall have a qualified and currently certified administrator.. This requirement was not met as evidence by:
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Licensee agreed to hire a new administrator and provide all required documents to change the administraor name in the system by the POC date.
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Based on information obtained, the Licensee did not comply with the section cited above. The facility has not had a certified administrator since June 6, 2025. This poses a potential health and safety risk to residents in care.
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Type B
11/13/2025
Section Cited
CCR87618(b)(3)(c)

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The licensee shall be responsible for the following: (3)Ensuring that the use of oxygen equipment meets the following requirements: (c) Smoking shall be prohibited where oxygen is in use. This requirement was not met as evidence by:
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Licensee will conduct in service training reviewing this section of the regulation. Licensee will provide all training materials and signatures of all staff that have attended the training by the POC due date.
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Based on observation,the Licensee did not comply with the section cited above. LPA detected the smell of cigarette smoke during the physical plant tour. LPA observed that R4 uses oxgygen. This poses a potential health and safety risk to residents in care.
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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:
Mariana Agban
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 11/06/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/06/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/06/2025 02:50 PM - It Cannot Be Edited


Created By: Mariana Agban On 11/06/2025 at 02:07 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: SUNNY SENIOR CARE
FACILITY NUMBER: 197610735

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/06/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/27/2025
Section Cited
CCR
87412(a)

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The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:
This requirement was not met as evidence by:
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Licensee agreed to provide LIC 500 by the POC date.
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Based on information obtained, the Licensee did not comply with the section cited above. Licensee was unable to provide LIC 500 as there was no employee schedule is in place. This poses a potential health and safety risk to residents in care.
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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:
Mariana Agban
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 11/06/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/06/2025


LIC809 (FAS) - (06/04)
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