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

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197610852
Report Date: 03/18/2026
Date Signed: 03/18/2026 03:29:11 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/10/2026 and conducted by Evaluator Evelin Rios
COMPLAINT CONTROL NUMBER: 31-AS-20260310162420
FACILITY NAME:ASH 1 LLCFACILITY NUMBER:
197610852
ADMINISTRATOR:MIRZAKHANIAN, ARIGAFACILITY TYPE:
740
ADDRESS:4019 W AVENUE J5TELEPHONE:
(818) 469-2001
CITY:LANCASTERSTATE: CAZIP CODE:
93536
CAPACITY:6CENSUS: 5DATE:
03/18/2026
UNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Arlen Shahverdian - LicenseeTIME COMPLETED:
03:35 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff do not ensure that resident is taking medication as prescribed.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Evelin Rios arrived to this facility to conduct and unannounced complaint visit. LPA was greeted by Staff # 1(S1) who contacted the licensee, Arlen Shahverdian. LPA explained the reason for the visit via telephone. Licensee met LPA shortly after. In the facility LPA observed three (3) out of five (5) residents and one (1) staff preparing medication.

The investigation consisted of the following: A physical plant tour was conducted to ensure the health and safety of residents in care. LPA did not observe any health or safety concerns or issues. From 9:00 AM to 1:00 PM, LPA interviewed three (3) out of five (5) residents. Two (2) residents were not in the facility during time of visit. LPA interviewed S1 and the licensee. LPA requested and obtained copies of the following documents: Register of Facility Residents (LIC 9020), Personnel Report (LIC 500), residents' Physician's Report (LIC602), Appraisal Needs and Services, and Centrally Stored Medication records. LPA also reviewed residents' centrally stored medication and the facility's program. (Continue to LIC9099-C)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Mary G Flores
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE:

DATE: 03/18/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
Control Number 31-AS-20260310162420
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 03/18/2026
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 investigation revealed the following: Regarding the allegation: Staff do not ensure that resident is taking medication as prescribed. It was alleged that morning medications are not administered properly.
LPA's interview with two (2) out of three (3) residents present in the facility stated staff provide all medication prescribed. Interview with one (1) resident stated they have noticed the number of pills they are provided is different from one day to the next. They believe at least two medications have not be provided. LPA's review of the Centrally Stored Medication, Centrally Stored Medication Record (CSMR) and Medication Administration Record (MAR) revealed Resident #1(R1) had an alternative allergy medication prescribed with filled date 03/04/2026. LPA did not observe the medication documented on the MAR or CSMR. Review of the MAR revealed the originally prescribed medication was discontinued or no longer provided after 03/04/2026 without the new alternative medication being provided. R1 confirms they have not been provided the medication. LPA also observed an as needed or PRN medication with filled date 03/10/2026 was not documented in R1's MAR or CSMR. R1 confirmed they had not needed to request to take the PRN medication. The licensee stated they were not aware medication had changed or had been delivered and would immediately address the issue. S1 confirmed they have not provided the new medication.

Based on LPAs observations, interviews and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated.

An exit interview was conducted, California Code of Regulations, Title 22, Division 6, Chapter 8 are being cited on the attached LIC 9099D and a copy of this report was given to administrator with the Appeal Rights.

SUPERVISORS NAME: Mary G Flores
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE:

DATE: 03/18/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/10/2026 and conducted by Evaluator Evelin Rios
COMPLAINT CONTROL NUMBER: 31-AS-20260310162420

FACILITY NAME:ASH 1 LLCFACILITY NUMBER:
197610852
ADMINISTRATOR:MIRZAKHANIAN, ARIGAFACILITY TYPE:
740
ADDRESS:4019 W AVENUE J5TELEPHONE:
(818) 469-2001
CITY:LANCASTERSTATE: CAZIP CODE:
93536
CAPACITY:6CENSUS: 5DATE:
03/18/2026
UNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Shonda Carpenter - StaffTIME COMPLETED:
03:35 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff do not ensure that resident is provided comfortable living accommodations.
Staff yelled at resident.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Evelin Rios arrived to this facility to conduct and unannounced complaint visit. LPA was greeted by Staff # 1(S1) who contacted the licensee, Arlen Shahverdian. LPA explained the reason for the visit via telephone. In the facility LPA observed three (3) out of five (5) residents and one (1) staff preparing medication.

The investigation consisted of the following: A physical plant tour was conducted to ensure the health and safety of residents in care. LPA did not observe any health or safety concerns or issues. From 9:00 AM to 1:00 PM, LPA interviewed three (3) out of five (5) residents. Two (2) residents were not in the facility during time of visit. LPA interviewed S1 and the licensee. LPA requested and obtained copies of the following documents: Register of Facility Residents (LIC 9020), Personnel Report (LIC 500), residents' Physician's Report (LIC602), Appraisal Needs and Services, and Centrally Stored Medication records. LPA also reviewed residents' centrally stored medication and the facility's program. (Continue to LIC9099-C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Mary G Flores
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE:

DATE: 03/18/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 31-AS-20260310162420
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 03/18/2026
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
Regarding the allegation: Staff do not ensure that resident is provided comfortable living accommodations. It was alleged that resident(s) who smoke, are jeopardizing resident's health. LPA's review of the facility program only found that cigarettes should be kept inaccessible to clients with dementia and smoking is not mentioned in the program. According to the licensee nobody is allowed to smoke in the facility and the facility has a designated smoking area in the backyard. LPA's interview with two (2) out of three (3) residents present in the facility stated they smoke outside in a designated area and do not smoke indoors. Interview with one (1) of the three (3) residents stated although they have not witnessed residents smoking in the facility sometimes the door is slightly open and smoking residents are closer to the door then the designated area. Interview with S1 and the licensee deny anyone has smoked indoors and residents smoke in a designated area.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated.

Regarding the allegation: Staff yelled at resident. It was alleged that the licensee yelled at a resident. LPA's interview with two (2) out of three (3) residents present in the facility deny being yelled at by the licensee and deny witnessing the licensee yell at another resident. Interview with one (1) resident stated the licensee had yelled at them with a raised voice after dismissing their concerns. Interview with S1 and the licensee deny yelling at residents or witnessing another staff yell at residents. S1 states residents may yell at staff. Interview with the licensee revealed he had a conversation with Resident #1 (R1) but he never raised his voice and plainly stated to the resident that if they are truly unhappy nobody was forcing the resident to stay since they felt they were trying their best to accommodate the resident's requests. The licensee went on to say they are not sure if this was the incident the allegation was addressing but it was the only conversation that stood out to them. LPA was unable to find a witness to the licensee yelling at residents.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated.

Exit interview conducted. Copy of report provided to the administrator.
SUPERVISORS NAME: Mary G Flores
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE:

DATE: 03/18/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2026
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 31-AS-20260310162420
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/18/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/02/2026
Section Cited
CCR
87465(a)(4)
1
2
3
4
5
6
7
87465 Incidental Medical and Dental Care(a) A plan for incidental medical and dental care shall be developed by each facility... (4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met by:
1
2
3
4
5
6
7
The licensee agreed to conduct in-service training with staff regarding medication. Licensee will provide LPA with a copy of the in service training sign in and material used to the department by POC due date 04/02/2026.
8
9
10
11
12
13
14
Based on the observations, interviews and
record reviews, the licensee did not ensure R1 was provided their daily prescribed allergy medication which poses in potential Health, Safety or Personal Rights risks to person in care.
8
9
10
11
12
13
14
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Mary G Flores
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE:

DATE: 03/18/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2026
LIC9099 (FAS) - (06/04)
Page: 5 of 5