198603213-12-5-2025-31-AS-AAEA-DP422P-20251205160105

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603213
Report Date: 12/05/2025
Date Signed: 12/05/2025 04:01:15 PM

Document Has Been Signed on 12/05/2025 04:01 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:	COMFORT CARE ASSISTED LIVING FACILITY		FACILITY NUMBER:	198603213
ADMINISTRATOR/ DIRECTOR:	AVETIKYAN, OLGA		FACILITY TYPE:	740
ADDRESS:	731 MILFORD STREET		TELEPHONE:	(747) 283-6125
CITY:	GLENDALE	STATE: CA	ZIP CODE:	91203
CAPACITY: 6		CENSUS: 5	DATE:	12/05/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:45 AM
MET WITH:	Manager/Caregiver, Susanna Avetian & Licensee, Emma Pogosian		TIME VISIT/ INSPECTION COMPLETED:	04:10 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	At 9:45a.m., Licensing Program Analyst (LPA) Antonia Alvizar-Ettima conducted an unannounced Required One (1) year inspection to the facility. Upon arrival, LPA met with Manager/Caregiver whom granted entry to the facility and explained the reason for the visit. Later Licensee joined today’s visit. At approximately 10:15a.m., LPA and Manager/Caregiver conducted a physical plant tour inside and out. During the tour, LPA observed that the facility is a one-story home located in a residential community. The home has four (4) bedrooms, two (2) full bathrooms, one (1) 1/2 bathroom; living room / dining area, and kitchen. There is a small office located next to front door. Required postings were observed in the entry area. The smoke alarms are operational, located in each bedroom and hallways. Front yard landscape is in good condition at time of this visit. There is a carbon monoxide detector that functions properly. The fire extinguisher is in the kitchen with purchased date of 12/10/2024. During the visit the facility is at 74 degrees Fahrenheit. The facility is licensed to serve 6 (six) non- ambulatory residents ages 60 and over of which 1 (one) may be bedridden and facility is approved to retain six (6) residents on hospice. The facility cares for elderly residents with dementia. Fire Emergency drill was last conducted on 11/10/2025. The facility is currently occupying five (05) residents. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: Kitchen: LPA observed kitchen appliances and fixtures were functional. The kitchen has a working gas stove, faucet, freezer, refrigerator, and microwave. LPA found at least two (02) days perishable and seven (07) Cont. on LIC 809-C

NAME OF LICENSING PROGRAM MANAGER: Naira Margaryan
NAME OF LICENSING PROGRAM ANALYST: Antonia Alvizar-Ettima
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 12/05/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2025

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: COMFORT CARE ASSISTED LIVING FACILITY	FACILITY NUMBER: 198603213
	VISIT DATE: 12/05/2025

NARRATIVE

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Cont. from LIC 809
days non-perishable food at the facility that is properly stored. Frozen foods are wrapped and stored properly as well. Knives were stored in a locked drawer in the kitchen. Food storage and preparation areas are clean and inaccessible to pests. Garbage cans have tight fitting covers. Toxic cleaning supplies were stored and locked away in the kitchen cabinet and laundry room closet.
Medications: Medications are in a centrally stored and locked medication cabinet in office area, including over-the-counter medicines; medications are properly labeled and checked for expiration dates. Each centrally stored prescription and PRN medication has been logged in the medications log with proper documentation from the resident’s doctor. First-aid has all proper items and were observed to be stored in a locked cabinet in the office area. Laundry Room: LPA observed washer and dryer machines located adjacent to the kitchen. Bedrooms: All residents bedrooms were properly furnished with appropriate dresser, beddings, and linens with sufficient lighting. Hallways are well lit. Linens are stored in resident room closet and observed to have ample supply of clean linen, comforters, and towels in facility. Bathrooms: LPA observed bathrooms to be clean, sanitary and with necessary supplies. The appropriate grab bars and mats in the showers. Hot water temperature measured at a range of 118.0°F to 118.4°F and within the required range. Resident’s personal hygiene supplies are kept separate in plastic containers. Towels and washcloths are not shared. Common Areas: These included the dining area and living room for residents. The common areas were properly furnished and observed to be in good repair. Residents dining table fits six (06) residents. No obstructions and/or tripping hazards throughout the facility. Surrounding Grounds: Entry and exits were free of obstruction. The facility has appropriate outdoor furniture with a shaded covered area for residents and visitors. The outdoor area was enclosed, and no bodies of water were observed. Two (2) storage sheds with extra supplies, observed to be locked and inaccessible to residents in care. Staff Files: Staff files all have criminal record clearances and are associated to facility. Staff have current first aid and training documentation showing training completed. Administrator's certificate was observed to be current. Resident Records: All five (05) resident records were reviewed. Residents’ records are complete and current at this time. Staff and residents files locked and inaccessible. Residents were also interviewed.

Facility is within CA code of Regulations Title 22 or Health and Safety Code. No deficiencies were found, exit interview conducted, copy of report was provided.

NAME OF LICENSING PROGRAM MANAGER: Naira Margaryan
NAME OF LICENSING PROGRAM ANALYST: Antonia Alvizar-Ettima
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 12/05/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2025

LIC809 (FAS) - (06/04)

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