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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610852
Report Date: 10/22/2025
Date Signed: 10/23/2025 10:35:37 AM

Document Has Been Signed on 10/23/2025 10:35 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:ASH 1 LLCFACILITY NUMBER:
197610852
ADMINISTRATOR/
DIRECTOR:		MIRZAKHANIAN, ARIAFACILITY TYPE:
740
ADDRESS:4019 W AVENUE J5TELEPHONE:
(818) 469-2001
CITY:LANCASTERSTATE: CAZIP CODE:
93536
CAPACITY: 6CENSUS: 0DATE:
10/22/2025
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:20 AM
MET WITH:Arlen Shahverdian and Ariga MirzakhanianTIME VISIT/
INSPECTION COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Evelin Rios conducted a Pre-Licensing inspection with both the applicant representative and administrator, Arlen Shahverdian and Ariga Mirzakhanian. An application to operate a Residential Care Facility for the Elderly was received by Community Care Licensing (CCL) on July 8, 2025. The fire clearance was approved on 07/17/2025 for six (6) non-ambulatory residents for a total capacity of six (06).
A tour of the physical plant was initiated at approximately 9:45am and the following was observed:

COMMON AREAS: These include the living room and dining room. The living room is furnished with sufficient seating, couches, and table. There is a fireplace that is secured with a screen. No fireplace tools present. The dining room table can accommodate the capacity. Common areas were observed free from any hazards.

BEDROOMS: There are four (4) bedrooms designated for resident use. Bedroom #1 and #2 are shared rooms. Bedroom #3 and #4 are private. The resident bedrooms are furnished with beds, night stand, chairs, chest of drawers, bedding and linen. The bedrooms have sufficient lighting and closet space. Passageways and exits from each bedroom are free and clear of any obstruction.

The smoke alarms and carbon monoxide detector are dual, hard wired and inter-connected. The facility has one fire extinguisher, located at the kitchen/dining room area. The fire extinguisher was purchased on June 11, 2025. (Continue to LIC809)
NAME OF LICENSING PROGRAM MANAGER: Nichelle Gillyard
NAME OF LICENSING PROGRAM ANALYST: Evelin Rios
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 10/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/22/2025
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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: ASH 1 LLC
FACILITY NUMBER: 197610852
VISIT DATE: 10/22/2025
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BATHROOMS: The facility has two (2) bathrooms. Bedroom #1 has it's own private bathroom with shower. The second bathroom, is located in the hallway by the other resident bedrooms. Both bathrooms were observed to have the proper fixtures, grab bars, and non-skid flooring. The hot water temperature was test in the hallway bathroom and measured 113.4 degrees Fahrenheit.

KITCHEN: The kitchen area is equipped with a refrigerator, stove/oven, dishwasher, microwave and sink. At this time, perishable food items are not required as there are zero (0) residents. There is an adequate supply of nonperishable and emergency food stored in the garage. There is also sufficient dining ware to accommodate the capacity of the facility. Knives and sharps were observed locked in a kitchen drawer.

LAUNDRY ROOM / GARAGE: The laundry room is equipped with a washer and dryer. The laundry room is able to lock making inaccessible to residents. Detergents, and cleaning supplies will be stored locked in a cabinet above the washer and dryer. There is an attached garage, accessible through the laundry room.

OUTSIDE: The backyard is entirely fenced in. There is a detached garage and shed used for storage. No bodies of water observed. There is sufficient space for outdoor activities.

MEDICATIONS / RECORDS: Medications and records will be stored in a closet the kitchen and laundry room. Closet will be able to lock. First aid kit and manual will be maintained in the medication closet.

Component III was conducted with the Licensee representative and the Administrator. Pre-Licensing is complete, and this facility has no deficiencies. This report will be sent to Centralized Application Bureau (CAB). You are not allowed to begin operating until you have been notified that your license has been approved by the CAB Analyst. Failure to comply could affect approval of your license.
Exit interview conducted. Copy of this report provided.
NAME OF LICENSING PROGRAM MANAGER: Nichelle Gillyard
NAME OF LICENSING PROGRAM ANALYST: Evelin Rios
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/22/2025
LIC809 (FAS) - (06/04)
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