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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610991
Report Date: 05/12/2026
Date Signed: 05/12/2026 12:49:16 PM

Document Has Been Signed on 05/12/2026 12:49 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:AD HARMONY HOUSEFACILITY NUMBER:
197610991
ADMINISTRATOR/
DIRECTOR:		HAKOBYAN, DAVITFACILITY TYPE:
740
ADDRESS:3059 N FREDERIC STREETTELEPHONE:
(323) 331-6889
CITY:BURBANKSTATE: CAZIP CODE:
91504
CAPACITY: 6CENSUS: 0DATE:
05/12/2026
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Davit HakobyanTIME VISIT/
INSPECTION COMPLETED:
12:45 PM
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Licensing Program Analyst (LPA) Nadia Shahbazian conducted an announced Pre-Licensing Inspection visit and met with Davit Hakobyan-Administrator. An Application to operate a Residential Care Facility for the Elderly (RCFE) was received by Community Care Licensing (CCL) on December 18, 2025. A fire clearance was approved on January 15, 2026 for Five (5) Non-ambulatory and One (1) Bedridden resident, for total capacity of Six (6).

Facility is an one-story rental house in a residential area. The house has been completely remodeled, all appliances and furnishings are brand new. Office area is located by the entry door. The required posting were posted by the entry door, accessible to residents. The smoke and carbon monoxide detectors are dual and inter-connected and there is a fire, pull station by the entry door. At 10:06am, smoke and carbon monoxide detectors were tested and observed to be functional. In addition facility is equipped with a functional fire door in the living room, leading to bedrooms 2, 3 and 4. The facility has one fire extinguisher by the entry door, purchased on January 9, 2026.

A tour of the physical plant was initiated at 10:40am and the following was observed:

KITCHEN: The kitchen is equipped with brand new appliances, including a refrigerator, stove/oven, microwave. Knives were observed locked in a lockbox, on the counter top. Chemicals were observed locked underneath the sink. There is an installed water filter tank, underneath the kitchen sink. There was an adequate supply of perishable and non-perishable food items and supply of dishes in kitchen cabinets.

COMMON AREAS: The dining room is located by the kitchen and is furnished with a round table and six chairs. The living room is located by the dining room and is furnished with a coffee table and couches. LPA observed a television set and a cabinet stocked with games and art supplies, in the living room. Facility has land-line telephone, wi-fi and cable for resident's use. There are installed cameras in the common areas and in the front and back yard.

Continued on 809-C

NAME OF LICENSING PROGRAM MANAGER: Mary G Flores
NAME OF LICENSING PROGRAM ANALYST: Nadia Shahbazian
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/12/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/12/2026
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.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: AD HARMONY HOUSE
FACILITY NUMBER: 197610991
VISIT DATE: 05/12/2026
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BEDROOMS: There are four (4) bedrooms designated for resident's use and one (1) for live-in staff. Bedrooms # 1 and 4 are shared rooms. All residents bedrooms were furnished with beds, night-stands, chairs, closets, and supply of bedding and linens. Bedroom #1 and staff bedroom is located next to each other. A fire door in the living room, leads to bedrooms 2, 3 and 4. Bedrooms # 1 and 3 have exit doors leading to the backyard and will be designated as the bedridden bedrooms. Bedroom #3 also has a locked door, leading to the garage but the facility will keep the door locked, at all times.

BATHROOMS: There are total of two (2) bathrooms for resident and staff use. One of the bathrooms is located inside bedroom #1 and other is in between bedrooms 3 and 4. Both bathrooms were observed to have proper fixtures, grab bars, and non-skid mats. The hot water delivered in the bathrooms measured between 110.8 and 111.0 degrees Fahrenheit.

MEDICATION CABINET: Medications will be kept locked in a cabinet in a hallway closet. LPA observed two complete first aid kits and first aid manual in the medication cabinet.

OFFICE: Office area is located by the entry door but all resident and staff records will be maintained in the hallway medication cabinet.

SURROUNDING GROUNDS: All exit doors have functional auditory alerts, when opened. The living room door has two stairs and leads to the backyard. The front door has a ramp, in addition, bedrooms #1 and 3 which have exit doors with ramps; all these doors will be used as the emergency exits. All doors are clearly marked with exit signs on top. There is a covered patio in the backyard with furniture that includes a set of tables, chairs, appropriate for number of residents and staff. There is a fenced, locked swimming pool in the backyard. The washer and dryer was observed inside a shed in the backyard. A locked cabinet next to the shed is used to store laundry detergents and chemicals. Garage is attached to the front of the house with a door, leading to bedroom #3. The garage door leading to bedroom#3 will be kept locked, at all times.

In addition to the Pre-Licensing inspection, a Component III power point presentation was held. Pursuant to Title 22, Division 6 of the CA Code of Regulations, the facility's physical environment appears to be compliant and ready for licensure. CAB will be advised and a copy of this report was provided to the administrator.

NAME OF LICENSING PROGRAM MANAGER: Mary G Flores
NAME OF LICENSING PROGRAM ANALYST: Nadia Shahbazian
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/12/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2026
LIC809 (FAS) - (06/04)
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