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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610754
Report Date: 02/18/2026
Date Signed: 02/18/2026 12:24:51 PM

Document Has Been Signed on 02/18/2026 12:24 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:DIGNITY ASSISTED LIVING LLCFACILITY NUMBER:
197610754
ADMINISTRATOR/
DIRECTOR:		MAHMOODZADEH,NIRVANAFACILITY TYPE:
740
ADDRESS:11000 NOBLE AVETELEPHONE:
(818) 913-7799
CITY:MISSION HILLSSTATE: CAZIP CODE:
91345
CAPACITY: 6CENSUS: 6DATE:
02/18/2026
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:30 AM
MET WITH:Administrator - Nirvana MahmoodzadehTIME VISIT/
INSPECTION COMPLETED:
12:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Evelin Rios conducted a Case Management - Deficiencies visit in conjunction with the complaint control number 31-AS-20260209085900 investigation today.

Upon entry to the facility, LPA observed two staff members, Staff #1 (S1) and Staff #2 (S2), providing assistance with activities of daily living to residents. LPA requested the Personnel Report (LIC 500) from the Administrator, who provided a copy that was being updated during the visit. LPA’s review of the facility’s roster in Guardian showed only the Administrator and one additional individual, who was not present at the facility, as cleared and associated. During LPA's interview with the Administrator they stated that a criminal record transfer request had been submitted for S1 and wasn't sure why S1 was not showing up as associated. S2 had recently started working, and the Administrator reported they were in the process of obtaining fingerprint clearance. LPA requested to review staff files, however, the Administrator was unable to provide them, stating that they were not physically at the facility because they were in the process of organizing the files.




Deficiency issued (refer to LIC809-D). Civil penalty assessed (refer to LIC 421BG). Appeals provided. Copy report issued.
NAME OF LICENSING PROGRAM MANAGER: Mary G Flores
NAME OF LICENSING PROGRAM ANALYST: Evelin Rios
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 02/18/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/18/2026
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 02/18/2026 12:24 PM - It Cannot Be Edited


Created By: Evelin Rios On 02/18/2026 at 11:23 AM
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: DIGNITY ASSISTED LIVING LLC
FACILITY NUMBER: 197610754

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/18/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/19/2026
Section Cited
CCR
87355(e)(2)

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Criminal Record Clearance (e) All individuals subject to a criminal record review ... shall prior to working, residing or volunteering in a licensed facility: 2)Obtain a California clearance or a criminal record exemption as required by the Department... This requirement was not met as evidence by:
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The licensee agreed that the staff member will not return to work until fingerprint clearance is completed and the staff member is properly associated to the facility. The licensee will provide a copy of the fingerprint clearance to the LPA once obtained.
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Based on interviews, and Guardian record review the licensee did not comply with the section cited above in having S2 working on 02/18/2026 without fingerprint clearance, which poses an immediate health, safety or personal rights risk to persons in care.
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Type A
02/19/2026
Section Cited
CCR87355(e)(3)

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Criminal Record Clearance (e) All individuals subject to a criminal record review ... shall prior to working, residing or volunteering in a licensed facility:(3) Request a transfer of a criminal record clearance as specified in Section 87355(c)...
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Licensee agreed that the staff member will not return to work until they are properly associated to the facility. The licensee shall complete the association process and provide proof of association to the LPA by 02/19/2026.
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Based on interview, and Guardian record review the licensee did not comply with the section cited above by not associating the S1 to the facility since, which poses an immediate health, safety or personal rights risk to persons 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.
Mary G Flores
NAME OF LICENSING PROGRAM MANAGER:
Evelin Rios
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 02/18/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/18/2026


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 02/18/2026 12:24 PM - It Cannot Be Edited


Created By: Evelin Rios On 02/18/2026 at 11:49 AM
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: DIGNITY ASSISTED LIVING LLC
FACILITY NUMBER: 197610754

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/18/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/27/2026
Section Cited
CCR
87412(g)

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Personnel Records (g) All personnel records shall be maintained at the facility and shall be available to the licensing agency for review.
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The administrator agreed to bring files to the facility and provide copies to LPA by 02/27/2025.
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Based on interviews, the licensee did not comply with the section cited above in not having S1's and S2's records readily available for review which poses an potential health, safety or personal rights risk to persons 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.
Mary G Flores
NAME OF LICENSING PROGRAM MANAGER:
Evelin Rios
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 02/18/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/18/2026


LIC809 (FAS) - (06/04)
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