<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610769
Report Date: 12/11/2025
Date Signed: 12/11/2025 03:32:19 PM

Document Has Been Signed on 12/11/2025 03:32 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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:SAINT MARIAM'S CARE CENTER INCFACILITY NUMBER:
197610769
ADMINISTRATOR/
DIRECTOR:		VARDANYAN, ANAHITFACILITY TYPE:
740
ADDRESS:15649 CHASE STREETTELEPHONE:
(747) 313-1040
CITY:NORTH HILLSSTATE: CAZIP CODE:
91343
CAPACITY: 6CENSUS: 5DATE:
12/11/2025
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Elena Kordonskiy, AdministratorTIME VISIT/
INSPECTION COMPLETED:
03:40 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
At 10:00 am Licensing Program Analyst (LPA) Tihesha Smith made a subsequent announced visit to this facility to conduct Pre-licensing inspection. LPA was greeted by the Licensee and administrators (CA Identification verified.)

LPA Smith attempted initial pre-licensing inspection on 10/30/2025 and rescheduled to 11/13/2025. This licensing application is a plan of correction to unlicensed operation that was substantiated under complaint # 31-AS-20241022130708 on 10/29/2024.

The home is single story and has four (4) bedrooms/each with its own bathroom and 1(one) guest bath for a total of five (5) bathrooms. The common areas (kitchen, dining, and living room/office areas) were appropriately furnished, and lighting was adequate. Refrigerator stocked with adequate food supply. Freezer in hallways stocked with meats/poultry. Pantry closet stocked with canned foods, dry foods and ready meals. The appliances in the kitchen appeared to be functional. The sharps and first aid kit are stored and locked in hallway standalone cabinet near medications.

The living room has a television and comfortable furniture. Games and activities for residents are stored on the living room console table. There are two (2) wall mounted fire extinguishers in the home: One (1) dining room and one (1) in hallway located near bedroom #4. Both fire extinguishers observed to be fully charged.

Dual Smoke and Carbon Monoxide detectors were observed all over the facility, tested, and observed to be operational at 02:34 pm. Posting requirements in the living room and near front door.

Bedrooms have required furniture but need to be relocated. Extra linen/supplies stored on shelving in hallway.

NAME OF LICENSING PROGRAM MANAGER: Naira Margaryan
NAME OF LICENSING PROGRAM ANALYST: Tihesha Smith
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 12/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/11/2025
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 3
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)
Page: 2 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: SAINT MARIAM'S CARE CENTER INC
FACILITY NUMBER: 197610769
VISIT DATE: 12/11/2025
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
The hot water was tested for the bathrooms to be at 109. °F. Bathrooms have trash cans with lids, hand soap and paper towels, grab bars only in bathroom # 4. Medications stored and locked in hallway standalone. Facility files stored in small office cabinet. Toxins locked in guest bathroom standalone cabinet.

Laundry room in hallway and the appliances were observed to be in good repair. Covered patio with table and sufficient seating for residents to conduct outdoor activities.

Pool on property enclosed by fenced and observed to be locked an inaccessible. Facility observed to be clean and in good repair.

Component III was conducted with the administrator (Elena Kordonskiy) and understanding of Title 22 requirements confirmed by the administrator.

The following items identified need to be corrected:

The usage of the bedroom’s will be corrected on the facility sketch and sent to CAB specialist

Bedroom #1 has two individuals in room will be a shared room

Bedroom #1 Bathroom: Add grab bars and skid mats

Bedroom #2 will be the staff room---- Licensee will remove additional bedroom room sleeping arrangement out of the closet and relocate to bedroom # 3

Bedroom #2 bathroom: Add grab bars and skid mats

Bedroom #3 bathroom: Add grab bars and skid mats

Bedroom #4 is bedridden

Guest bathroom: Add grab bars

Elena Kordonskiy will be the administrator/ Licensee will send administrators certificate to CAB Specialist

Licensee has power of attorney (POA) for an individual that she stated will be a resident. Licensee will need to provide notarized POA revocation form

Copy of this report will be forwarded to the CAB specialist.

Exit interview conducted/Copy of report given.

NAME OF LICENSING PROGRAM MANAGER: Naira Margaryan
NAME OF LICENSING PROGRAM ANALYST: Tihesha Smith
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2025
LIC809 (FAS) - (06/04)
Page: 3 of 3