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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610745
Report Date: 05/15/2025
Date Signed: 05/15/2025 03:05:58 PM

Document Has Been Signed on 05/15/2025 03:05 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.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:PALMDALE PARADISE BOARD & CAREFACILITY NUMBER:
197610745
ADMINISTRATOR/
DIRECTOR:		GALSTYAN, SONAFACILITY TYPE:
740
ADDRESS:40117 25TH STREET WTELEPHONE:
(626) 310-3333
CITY:PALMDALESTATE: CAZIP CODE:
93551
CAPACITY: 6CENSUS: 0DATE:
05/15/2025
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Sona GalstyanTIME VISIT/
INSPECTION COMPLETED:
12:15 PM
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On 5/15/2025 Licensing Program Analyst (LPA) Melissa Spaeth conducted an announced pre-licensing visit to this facility and met with the Applicant, Sona Galstyan. This is a new application. A fire clearance dated 1/23/2025 was received for five (5) non-ambulatory residents and one bedridden resident for a total of six residents. The licensee has requested a hospice waiver for six residents.

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. Component III was conducted with the applicant from 9:30 until 10:00 am.

Today’s site visit consisted of LPA touring the physical plant inside and outside from 10:00 am until 10:45 am LPA Spaeth observed the following:

Office – contained a bed but the licensee confirmed the room will not be used as a sleeping area for residents or staff.

Dining Room - The dining room contained a dining room table and chairs.

Living Room– the living room contained comfortable seating.

Hallway Closet - The hallway closet contained a first aid kit. The resident medication and files will also be stored in the locked closet.

Continued 809-C

NAME OF LICENSING PROGRAM MANAGER: Troy Agard
NAME OF LICENSING PROGRAM ANALYST: Melissa Spaeth
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/15/2025
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.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: PALMDALE PARADISE BOARD & CARE
FACILITY NUMBER: 197610745
VISIT DATE: 05/15/2025
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Kitchen - The knives were locked in a kitchen cabinet. A fire extinguisher is located in the kitchen area.

Game Room - LPA observed the game room is supplied board games.

Laundry Room and Garage –The room was locked and contained a washer and dryer, the laundry soap and cleaning solutions. A door leads to the garage and that door was locked.

Water Temperature - The water temperature was tested at 10:30 am and was 108 degrees F.

Bathrooms- The bathrooms contained hand soap, slip resistant mats, paper towels, grab bars and a trash can.

Bedrooms – The bedrooms contained bed, linens, night stand, chest of drawers, a chair, and a closet.

Backyard - The backyard contains a shaded area with comfortable seating, a golf putt area, and a swimming pool. A fence surrounds the swimming pool and the swimming pool gate was locked. A locked shed is located in the backyard and contained pool supplies.

Front Yard -. LPA Spaeth observed a fountain which was filled with sand to ensure the safety of the residents in care. LPA also observed a swing set, slide and a rock landscape that should be removed from the property. The applicant will remove the swing set and slide. A safety fence will be installed around the perimeter of the landscaped area.

Smoke /carbon monoxide detectors - The smoke/carbon monoxide detectors were tested at 10:40 am and were operable.

The applicant will make the required changes to the property and will contact LPA Spaeth upon completion of the changes. A second inspection will be conducted by LPA Spaeth at a later date.

Exit interview conducted and a copy of the report was given.

NAME OF LICENSING PROGRAM MANAGER: Troy Agard
NAME OF LICENSING PROGRAM ANALYST: Melissa Spaeth
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2025
LIC809 (FAS) - (06/04)
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