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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610763
Report Date: 07/03/2025
Date Signed: 07/03/2025 11:28:05 AM

Document Has Been Signed on 07/03/2025 11:28 AM - 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:AMERICAN DREAM ASSISTED LIVINGFACILITY NUMBER:
197610763
ADMINISTRATOR/
DIRECTOR:		GASPARYAN, ANNAFACILITY TYPE:
740
ADDRESS:8542 LURLINE AVETELEPHONE:
(747) 254-5013
CITY:WINNETKASTATE: CAZIP CODE:
91306
CAPACITY: 6CENSUS: 0DATE:
07/03/2025
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Anna Gasparyan - AdministratorTIME VISIT/
INSPECTION COMPLETED:
12:00 PM
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On 7/3/2025 at 9:30AM Licensing Program Analyst (LPA), Perchui Milena Khurshudyan conducted an announced Pre-Licensing visit to the above facility and met with facility Administrator Anna Gasparyan. LPA introduced herself by showing her department badge and conducted entrance interview. Fire Clearance was approved on 02/12/2025 for a maximum capacity of six (6) non-ambulatory residents, of which one (1) can be Bedridden resident in bedroom #5. Facility has a Dementia Care Program. The purpose of today’s visit is to inspect the facility to ensure that the facility is in compliance with rules and regulations under the California Code of Regulations, Title 22. The facility is a single-story building. Today's site visit consisted of LPA touring the physical plant inside and outside and observed the following:

KITCHEN: The facility has a Kitchen area that is equipped with a new refrigerator, microwave oven and sink. At 9:45AM, LPA observed adequate supplies of nonperishable food properly stored inside the kitchen cabinets. Perishable food items are not required at this time as there are no residents in the facility. Licensee will supply sufficient amount of perishable food upon arrival of the residents. LPA observed dining ware to accommodate a maximum capacity of six (6) residents. All knives and sharps are observed to be locked in a kitchen cabinet and inaccessible to residents in care. The facility has one (1) new fire extinguisher, which was purchased on 02/04/2025.

BEDROOMS: There are five (5) bedrooms designated for residents’ use. All bedrooms are furnished with beds, dressers, chairs, nightstands and required bedding and linen. The bedrooms have sufficient closet space and have sufficient lighting. Auditory alarms were tested and observed to be operational at 10:20AM. There is no bedroom designated for staff use. Facility will have awake staff at night.

Continue On LIC809-C

NAME OF LICENSING PROGRAM MANAGER: Nichelle Gillyard
NAME OF LICENSING PROGRAM ANALYST: Perchui Khurshudyan
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/03/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4
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: AMERICAN DREAM ASSISTED LIVING
FACILITY NUMBER: 197610763
VISIT DATE: 07/03/2025
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LAUNDRY ROOM: The laundry area is next to the kitchen. The washer and dryer machines appear to be new and in good condition. Laundry supplies along with other chemical items observed locked and under supervision when not in use.

BATHROOMS: Facility has three (3) bathrooms. At 10:35am LPA observed all bathrooms are clean, in good repair and properly supplied with toilet paper, soap and paper towels. LPA observed appropriate grab bars and non-skid mats in all bathrooms. Trash cans had closed tight fitting lids. Water temperature was within regulation, and it was measured by an LPA at 10:50am to be at 106.3°F degrees.

COMMON AREAS: The facility maintains a comfortable temperature at 72°F. The living room and dining area appeared clean and were properly furnished. Activity supplies were nicely organized inside the office area. Activities include puzzles, coloring books, crayons, and board games. No obstructions or tripping hazards throughout the facility. An emergency exit plan/sketch is posted along the hallway with other posting requirements. The facility has a fireplace which is properly fenced. LPA informed the fireplace is not operational. No firearms observed or will be maintained on the premises.

MEDICATION: The medication will be kept inside the commercial cabinet which is placed between the dining and kitchen area. The facility staff/resident files will be kept centrally stored and locked in the office area between the living room and the kitchen. First-aid kit was checked to be complete and has the new manual available. The facility will operate with two (2) shifts (AM and PM).

SMOKE DETECTORS/CARBON MONOXIDE. Dual smoke detectors and carbon monoxide were located in the bedrooms and throughout the facility. At 10:55am they were tested and observed to be operational.

SURROUNDING GROUNDS: The facility has sufficient yard space. LPA observed appropriate outdoor furniture, with a covered shaded area for residents. The backyard is fenced. LPA discussed the importance of maintaining care and supervision to meet the needs of the residents. There is a pool in the backyard, properly fenced and locked. The facility has land line, LPA checked to be operational.

LPA observed the facility is clean, safe and sanitary. All window screens were in good repair. Auditory signals were installed on all exit doors. All passageways were free of obstruction.

Continue on LIC809-C

NAME OF LICENSING PROGRAM MANAGER: Nichelle Gillyard
NAME OF LICENSING PROGRAM ANALYST: Perchui Khurshudyan
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/03/2025
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: AMERICAN DREAM ASSISTED LIVING
FACILITY NUMBER: 197610763
VISIT DATE: 07/03/2025
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GARAGE: The garage is currently being used as storage for facility equipment, supplies and water. The garage is attached to the facility; however, it has no access from the house.

Component III: On 7/3/2025 during Pre-Licensing visit at the facility, the Administrator Anna Gasparyan completed Component III. At which time it was explained how to operate the facility within substantial compliance, The Administrator also had an opportunity to ask questions.

Based on inspection and observation, the physical plant is in compliance with Title 22 Regulations at this time. This report will be forwarded to the Centralized Application Bureau (CAB) and the applicant will be notified by the CAB Analyst when the license has been approved.

Exit interview conducted and copy of this report signed and delivered to the Administrator.

NAME OF LICENSING PROGRAM MANAGER: Nichelle Gillyard
NAME OF LICENSING PROGRAM ANALYST: Perchui Khurshudyan
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/03/2025
LIC809 (FAS) - (06/04)
Page: 4 of 4