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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610911
Report Date: 03/26/2026
Date Signed: 03/26/2026 01:39:35 PM

Document Has Been Signed on 03/26/2026 01:39 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.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:HEALING PINES SENIOR LIVING LLCFACILITY NUMBER:
197610911
ADMINISTRATOR/
DIRECTOR:		GHUKASYAN, KRISTINEFACILITY TYPE:
740
ADDRESS:19733 HEMMINGWAY STTELEPHONE:
(747) 352-2385
CITY:WINNETKASTATE: CAZIP CODE:
91306
CAPACITY: 6CENSUS: 5DATE:
03/26/2026
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Ghukasyan Kristine - AdministratorTIME VISIT/
INSPECTION COMPLETED:
01:15 PM
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On 3/26/2026 at 10:00am, Licensing Program Analyst (LPA) Perchui Milena Khurshudyan conducted a Pre-Licensing Inspection with the Administrator Ghukasyan Kristine. This is a Change of Ownership Application from facility #197610320 to #197610911 to operate an Residential Care Facility for Elderly (RCFE). A Change in Ownership (CHOW) Application to operate the RCFE was received by Community Care Licensing (CCL) on 9/19/2025. A fire clearance was approved on December 30th, 2025, for five (5) non-ambulatory residents, and one (1) Bedridden resident for bedroom # 3. Facility has Hospice waivers granted for six (6) residents. The smoke alarms and carbon monoxide detectors are hard wired and inter-connected; they were tested and are operational. The facility has two (2) fire extinguishers that were serviced on 3/14/2026 and will be located on the kitchen wall and in the hallway.

A tour of the physical plant was initiated at approximately 10:45am and the following was observed:

KITCHEN: The facility has a Kitchen area that is equipped with a refrigerator, gas stove, microwave oven and sink. There were adequate supplies of two (2) days of perishable and seven (7) days of nonperishable food, dining ware to accommodate a maximum capacity of six (6) residents. Knives and other sharps were observed locked inside the kitchen cabinets and chemicals observed stored inside locked cabinet under the sink.

COMMON AREAS: These include living room and a dining room. LPA observed the area was generally clean and organized. The living room was equipped with furniture, a television, tables and chairs. There is fireplace in the living room which is blocked and not accessible to residents. The dining area has a dining table to accommodate six (6) residents. There were no visible immediate hazards. The facility has comfortable temperature which was measured at 10:55am to be 70 degrees F. Continue on LIC809-C

NAME OF LICENSING PROGRAM MANAGER: Nichelle Gillyard
NAME OF LICENSING PROGRAM ANALYST: Perchui Khurshudyan
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 03/26/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/26/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4
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: HEALING PINES SENIOR LIVING LLC
FACILITY NUMBER: 197610911
VISIT DATE: 03/26/2026
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BEDROOMS: The facility has four (4) bedrooms, and all bedrooms are designated for residents' use. All residents' bedrooms were observed to be nicely furnished with beds, nightstands, lamps, chairs, dresser, bedding and linen. The bedrooms have sufficient lighting and closet space. Additional fresh linen is available inside the linen cabinet located in the hallway. Bedrooms #1 and #2 are for non-ambulatory residents and bedrooms #3 is for bedridden only.

BATHROOMS: The facility has two (2) bathrooms, both designated for residents’ and staff use. All bathrooms were observed to have the proper fixtures, grab bars, non-skid mats, trash cans with closed lids, paper towels/ hand dryer and washing hands signs. The hot water delivered in the bathrooms measured at 11:10am to be at 110.1 degrees. Bathroom #1 is located in the hallway next to bedroom #2 and bathroom #2 is inside bedroom #3.

GARAGE: LPA observed that there is a garage located on the premises and was informed by the licensee that they recently received approval to convert the structure into an Accessory Dwelling Unit (ADU). The licensee stated that the required documentation and notification related to this approval will be submitted to the department for review.

LAUNDRY ROOM: The washer and dryer is located in the hallway, inside a separate laundry area. Laundry chemicals are always locked and under supervision inside a separate cabinet.

Client Files: From 11:05am to 12:00pm LPA conducted a file review of all client records to ensure compliance of licensing forms. Clients’ files are complete and kept locked inside the kitchen cabinet.

Staff Files: Staff files are also kept inside a locked kitchen cabinet. From 12:00pm to 12:20pm LPA conducted staff file review, files were complete with all documents and training certificates.

MEDICATIONS: Medications are kept locked inside the kitchen cabinet. At approximately 12:15pm to 12:45pm LPA observed each centrally stored prescription and PRN medication has been logged in the medications log with proper documentation from the clients’ doctor. All medications are properly labeled and checked for expiration dates. First Aid and the new manual available and locked inside the kitchen cabinet along with medications. LPA observed the First-aid has all proper items and is current.

Continue on LIC809-C

NAME OF LICENSING PROGRAM MANAGER: Nichelle Gillyard
NAME OF LICENSING PROGRAM ANALYST: Perchui Khurshudyan
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/26/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/26/2026
LIC809 (FAS) - (06/04)
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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: HEALING PINES SENIOR LIVING LLC
FACILITY NUMBER: 197610911
VISIT DATE: 03/26/2026
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SURROUNDING GROUNDS: The driveway, passageways and entrance to the home were clear of obstruction. The backyard of the facility is properly fenced, has a patio and backyard furniture to accommodate six (6) residents. There is no pool or body of water in the premises. There are two (2) exit gates on both sides of the property, LPA checked gates were unlocked and easily accessible.

LPA observed the facility is clean, safe, sanitary and odorless. All window screens were in good repair. Auditory signals were installed on exit doors and operational. All passageways were free of obstruction.

In addition to the Pre-Licensing inspection, a Component III power point presentation was also held. Pursuant to Title 22, CA Code of Regulations, the facility's physical environment appears to be compliant and ready for licensure. CAB will be advised.

An emergency exit plan/sketch along with other posting requirements were available in the hallway next to the entrance.

No deficiency cited on today’s visit.

Exit interview conducted and copy of this report signed and delivered to the Licensee/Administrator.

NAME OF LICENSING PROGRAM MANAGER: Nichelle Gillyard
NAME OF LICENSING PROGRAM ANALYST: Perchui Khurshudyan
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/26/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/26/2026
LIC809 (FAS) - (06/04)
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