197610874-1-16-2026-31-AS-JGTN-DQDRXK-20260116122451

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610874
Report Date: 01/16/2026
Date Signed: 01/16/2026 12:25:06 PM

Document Has Been Signed on 01/16/2026 12:25 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
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	BOARD AND CARE AYC-2		FACILITY NUMBER:	197610874
ADMINISTRATOR/ DIRECTOR:	BABAYAN, KNARIK		FACILITY TYPE:	740
ADDRESS:	14952 POLK STREET		TELEPHONE:	(562) 600-6060
CITY:	SYLMAR	STATE: CA	ZIP CODE:	91342
CAPACITY: 6		CENSUS: 0	DATE:	01/16/2026
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:09 AM
MET WITH:	Knarik Babayan - Administrator		TIME VISIT/ INSPECTION COMPLETED:	12:15 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	Licensing Program Analysts (LPA) Jose Tan conducted an announced Pre Licensing visit to this facility and met with Licensee representative Knarik Babayan. The applicant is "Board and Care AYC 2". Fire Clearance dated 09/08/25 was received for six (6) non-ambulatory residents, one (1) of which maybe bedridden on Room #3. 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. Facility is a single storey home. Today's site visit consisted of LPA touring the physical plant at 9:22 AM inside and outside and observed the following: The facility smoke alarm system is hard wired and interconnected. The fire extinguisher is located near the dining area and was observed to be fully charged and last bought on 05/11/25. The facility uses a dual Carbon Monoxide/Smoke alarm detectors all over the common areas of the facility. Alarms were tested and observed to be operational. Hot water was tested in the common bathroom and measured at 119.3°F. There is a functioning telephone on the premises. An emergency exit plan/sketch is posted on the hallway wall with other posting requirements. There are three (3) resident bedrooms, all shared room. Resident bedrooms were observed to be appropriately furnished. The common areas (living room, kitchen, office and dining areas) were appropriately furnished and lighting was adequate. The living room has a comfortable furniture. Residents, staff records and medications will be stored in a designated secured filing cabinet in the bedroom hallway. (continued on LIC 809-C)

NAME OF LICENSING PROGRAM MANAGER: Troy Agard
NAME OF LICENSING PROGRAM ANALYST: Jose Gary Tan
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 01/16/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/16/2026

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
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: BOARD AND CARE AYC-2	FACILITY NUMBER: 197610874
	VISIT DATE: 01/16/2026

NARRATIVE

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(continued from LIC 809)

The first aid kit is readily available in the kitchen. There are two (2) bathrooms in the facility. The bathrooms have appropriate grab bars installed and non-skid mats.

The kitchen knives and sharps will be stored in a locked drawer in the kitchen. Kitchen cleaning supplies are stored in a locked cabinet below the sink. Laundry detergents, cleaning supplies and other toxins are stored in a locked cabinet below the sink. The laundry area is located adjacent to the kitchen. The necessary precautions have been made to the facility to safely house dementia residents such as auditory alarms on all doors and locked areas for centrally stored medications. Auditory alarms were tested and observed to be operational. Facility appears to be clean and in good repair. Appliances in the kitchen appeared to be functional.

There will be a screening station immediately upon entrance. Sign in sheet, hand sanitizer, gloves and masks will be available. Required poster are posted all over the facility. The facility had submitted a Mitigation and Infection plan.

There is a sitting area in the back and side yards for residents to conduct outdoor activities. The backyard is fenced. There is no body of water in the facility. There is a toolshed at the backyard which was observed to be locked during the visit. There is no garage at the facility only car ports on the side and front yard

Component III was waived as approved by LPM Troy Agard as the licensee has another existing RCFE facility in good standing.

Facility is in compliance with Title 22 Regulations at this time. This report will be forwarded to the Centralized Application Bureau (CAB). You will be notified by the CAB Analyst when your license has been approved.

Exit interview conducted and copy of this report issued

NAME OF LICENSING PROGRAM MANAGER: Troy Agard
NAME OF LICENSING PROGRAM ANALYST: Jose Gary Tan
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 01/16/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/16/2026

LIC809 (FAS) - (06/04)

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