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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610795
Report Date: 04/09/2026
Date Signed: 04/09/2026 01:21:31 PM

Document Has Been Signed on 04/09/2026 01:21 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:DEVOTED CARE ASSISTED LIVINGFACILITY NUMBER:
197610795
ADMINISTRATOR/
DIRECTOR:		MAHMOODZADEH, NIRVANAFACILITY TYPE:
740
ADDRESS:9229 VALJEAN AVETELEPHONE:
(747) 755-2120
CITY:NORTH HILLSSTATE: CAZIP CODE:
91343
CAPACITY: 6CENSUS: 0DATE:
04/09/2026
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:38 AM
MET WITH:Nona Virabyan, LicenseeTIME VISIT/
INSPECTION COMPLETED:
01:30 PM
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Licensing Program Analyst (LPA) Tihesha Smith conducted an announce pre-licensing visit at this facility. LPA Smith was greeted by Nirvana Ghaemi-Mahmoozadeh, Nona Virabyan, and Noraet Neshan (face recognition).

Purpose of today’s visit is to inspect the facility to ensure that the facility is following the rules and regulations of California Code of Regulations, Title 22, Division 6.

Today's site visit consisted of LPA Smith touring the physical plant inside and outside and the following was observed:

The facility is a single-story building with a capacity of six (6). The common areas (kitchen, and combination living and dining room) were appropriately furnished, and lighting was adequate. The kitchen food preparation was observed to be sanitary. No perishable food currently however, a supply of nonperishable and canned food in kitchen cabinets. The sharps are stored and locked in kitchen drawer. Automated sink soap locked under kitchen sink cabinet. The appliances in the kitchen appeared to be new, clean and functional. The living and dining room furniture was observed to be functional with adequate seating at the table and on the sofas. A television is wall mounted in the living room area. Games and activities for residents are stored on living room table next to phone and first aid kit.

The medications and toxins to be locked in hall closet across from main bathroom. Linens stored in closet near residents’ room. Laundry area is in kitchen closet. The laundry appliances observed to be new, clean and functional.

NAME OF LICENSING PROGRAM MANAGER: Naira Margaryan
NAME OF LICENSING PROGRAM ANALYST: Tihesha Smith
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/09/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/09/2026
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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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: DEVOTED CARE ASSISTED LIVING
FACILITY NUMBER: 197610795
VISIT DATE: 04/09/2026
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(Cont from 809)
There are two (2) fire extinguishers in the facility both observed to be charged: (1) fire extinguisher: attached to kitchen wall and the other attached to wall in residents’ hallway. Dual Smoke and Carbon Monoxide detectors were observed all over the facility, tested, and observed to be operational at time of visit. Dementia alarms on exit doors observed to be functional at time of visit.

Emergency exit plan/sketch is posted on the living room wall along with other posting requirements. Additional emergency postings to bedrooms will be added.

The facility has a total of six (6) bedrooms as follows: four (4) residents’ bedrooms with three (3) furnished with night stand, lamp, dresser, and chair and two (2) staff rooms. There are two (2) bathrooms in the facility. Bathrooms have trash cans, non-slip mats and grab bars. Bathroom water temperature measured at: 115 degrees Fahrenheit.

Staff and residents’ files stored in cabinet in staff area in living

Backyard has a patio area with large umbrella, table and eight (8) chairs that provide sufficient seating and are in good repair.

Garage: Has additional refrigerator, stores of emergency food/water/supplies and equipment for facility only.

Component III presentation was conducted at 11:25 am. and upon completion the administrator/licensee acknowledged understanding.

No hazards observed during visit and facility is following title 22 regulations.

A copy of this report will be sent to the CAB Specialist

Exit interview conducted and copy of report given

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

DATE: 04/09/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/09/2026
LIC809 (FAS) - (06/04)
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