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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610821
Report Date: 11/06/2025
Date Signed: 11/06/2025 12:41:36 PM

Document Has Been Signed on 11/06/2025 12:41 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:NORTH HILLS SENIOR LIVINGFACILITY NUMBER:
197610821
ADMINISTRATOR/
DIRECTOR:		PALEZYAN, ANIFACILITY TYPE:
740
ADDRESS:9742 HASKELL AVETELEPHONE:
(747) 236-4308
CITY:NORTH HILLSSTATE: CAZIP CODE:
91343
CAPACITY: 6CENSUS: 0DATE:
11/06/2025
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Ani Palezyan, AdministratorTIME VISIT/
INSPECTION COMPLETED:
12:45 PM
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Licensing Program Analyst (LPA) Tihesha Smith conducted an announced pre-licensing visit with the licensee. Identification of the Licensee was verified by photo ID.

The facility has a capacity of six (6). Application received for five (5) non-ambulatory and one (1) bedridden in room # 4.

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

The common areas (kitchen, living room, and dining/office areas) were appropriately furnished, and lighting was adequate. Cabinets stocked with canned and dried foods, with plenty of water in laundry area storage cabinets. The appliances in the kitchen appeared to be functional. The sharps are stored and locked in a drawer in kitchen and toxins locked under kitchen sink.

The living room has a television and comfortable furniture. There is also a television in the dining room. 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) in the kitchen/dining room and one (1) located near bedrooms #1 and #2. Both fire extinguishers observed to be fully charged.

NAME OF LICENSING PROGRAM MANAGER: Naira Margaryan
NAME OF LICENSING PROGRAM ANALYST: Tihesha Smith
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 11/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/06/2025
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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: NORTH HILLS SENIOR LIVING
FACILITY NUMBER: 197610821
VISIT DATE: 11/06/2025
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Dual Smoke and Carbon Monoxide detectors were observed all over the facility, tested, and observed to be operational at 12:15 pm. An emergency exit plan/sketch all over facility and in each bedroom and other posting requirements in the living room

There are three (3) bathrooms in the facility. The hot water was tested for the bathrooms and all bathroom’s hot water at 105. °F. Bathrooms have trash cans with lids, hand soap and paper towels, and grab bars.

There are five (5) resident bedrooms and one staff room. Extra linen stored in resident closets and staff room storage.

Medications to be stored and locked in tall office cabinet and staff files to be store in small office cabinet. Toxins locked under the kitchen sink. The first aid kit on living room shelf.

The necessary precautions have been made to the facility to safely house dementia residents such as auditory alarms on all entry/exit doors. Facility appears to be clean and in good repair.

Patio has screened gazebo with patio table and sufficient seating for residents to conduct outdoor activities.

Laundry room at end of kitchen. The appliances observed to be in good repair.

There is no body of water at the facility.

Component III was conducted with the administrator and understanding of Title 22 confirmed by the administrator.

This facility is ready to be licensed. 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: 11/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2025
LIC809 (FAS) - (06/04)
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