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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603787
Report Date: 12/11/2025
Date Signed: 12/11/2025 03:06:59 PM

Document Has Been Signed on 12/11/2025 03:06 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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:VARDA HOME INCFACILITY NUMBER:
198603787
ADMINISTRATOR/
DIRECTOR:		MARKOSIAN, ARMENFACILITY TYPE:
740
ADDRESS:1744 E ELIZABETH STTELEPHONE:
(626) 888-7858
CITY:PASADENASTATE: CAZIP CODE:
91104
CAPACITY: 6CENSUS: 4DATE:
12/11/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Caregiver Karine ChilingaryanTIME VISIT/
INSPECTION COMPLETED:
03:15 PM
NARRATIVE
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License Program Analysts (LPA) Luis De Leon conducted an unannounced annual required visit. LPA met with Caregiver Karine Chilingaryan who informed Administrator of today’s visit. Administrator Armen Markosian joined the visit a few minutes later. The purpose of today’s visit was explained. The facility is licensed to serve six (6) non-ambulatory residents, age 60 and over. The facility is approved for one (1) bedridden resident and six (5) hospice waiver.

The LPA use the Compliance & Regulatory Enforcement Tool (CARE) during today’s inspection. The visit consisted as follows:

FACILITY PHYSICAL PLANT
The facility is in a residential area and is made up of four (4) Resident bedrooms, two (2) full bathroom including a private bathroom, living room, Dining room, laundry room in the garage, front and backyard, and a detached car garage. There were no body of water observed in the property.

REVIEW OF FILES
Resident record review consisted of Admission Agreements, Identification and Emergency Info, Physicians Report, Consent Report, Individual Program Plan, Hospice plan for 2 residents, Personal Rights, and Centrally Store Medication. Staff record review consisted of Personnel Report, Health Screening, Criminal Record Statements, Fingerprint Clearance, and Training. LPA observed that S1-S4 were missing First Aid Certificate in file. In addition, S1 and S3 were missing Health Screening records. Deficiencies were noted and record in LIC-809D.
Report continues on page LIC-809C...
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Luis DeLeon
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 12/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/11/2025
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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Document Has Been Signed on 12/11/2025 03:06 PM - It Cannot Be Edited


Created By: Luis DeLeon On 12/11/2025 at 01:58 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: VARDA HOME INC
FACILITY NUMBER: 198603787

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/11/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(a)(4)
Incidental Medical and Dental Care Services
(4) The licensee shall assist residents with self-administered medications as needed.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above in one (1) out of four (4) residents did not have all their doctor prescribed medications present at the facility. Lorazepam 0.5 mg Tablet was missing from facility for R3 which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/12/2025
Plan of Correction
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Licensee shall place order to pharmacy to replace missing prescription or provide doctor's prescription order for alternative medication and provide CCLD with a photo via email of replaced prescription by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Fernando Fierros
NAME OF LICENSING PROGRAM MANAGER:
Luis DeLeon
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 12/11/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/11/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/11/2025 03:06 PM - It Cannot Be Edited


Created By: Luis DeLeon On 12/11/2025 at 01:58 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: VARDA HOME INC
FACILITY NUMBER: 198603787

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/11/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.618(c)(3)
Other Provisions
(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above S1-S4 did not have a current CPR/First aid cert which posed a potential health and safety or personal rights risk to persons in care.
POC Due Date: 12/19/2025
Plan of Correction
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Administrator will obtain a new CPR/First aid for S1-S4 and send to LPA by POC due date.
Type B
Section Cited
CCR
87412(a)(11)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) A health screening as specified in Section 87411, Personnel Requirements - General.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in which S1 and S3 did not have a health screening done upon hire which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/19/2025
Plan of Correction
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The licensee shall ensure all employees have a health screening performed by a physician on file and ensure that S1 and S3 obtains a health screening by POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Fernando Fierros
NAME OF LICENSING PROGRAM MANAGER:
Luis DeLeon
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 12/11/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/11/2025


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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: VARDA HOME INC
FACILITY NUMBER: 198603787
VISIT DATE: 12/11/2025
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Observations during facility tour:
  • Bedrooms were furnished with a bedframe, dresser, lamps, and chairs. LPA observed full bed rail for all four residents and physician’s orders for rails were on file for each resident. LPA observed that there was clean linen, bath towels, and personal hygiene with reasonable closet space available for Residents.
  • Wall and floors are in good repair. Facility temperature was 73 degrees F as read from thermostat. Hallways were clean and free of obstructions.
  • Kitchen appliances were in working order and clean. There is sufficient two (2) days of perishables and seven (7) day supply of non-perishable food. Dining room has sufficient seating area.
  • Toilets, showers, and water faucets are found in compliance with Title 22 regulations for temperature and function. Restrooms were stocked and clean. The water temperature was tested and measured. It was found in compliance with Title 22 regulations between 105º and 120º F degrees.
  • Sharps are locked inside a drawer in a kitchen island inaccessible to Residents. Also, disinfectants and cleaning supplies are locked and secured inaccessible to Residents under kitchen sink and in garage.
  • Smoke detectors were observed in all bedrooms and carbon monoxide detectors were observed in living room around kitchen area. One (1) fire extinguisher was observed. Last fire drill and disaster drill was conducted on 10/1/2025.
  • Front and back yards are free of hazards. Back yard has a shaded seating area for Residents to enjoy.
  • The medications are centrally stored and locked in the staff room. The facility uses the Medication Administration Record (MAR) log to document medications given. LPA reviewed medications for all four (4) Residents. LPA observed that one prescribed medication was missing for one resident (R3). A deficiency is noted on LIC-809D.
  • LPA conducted interviews with two staff and two residents.


Per California Code of Regulations, Title 22, and California Health and Safety Code, the deficiencies observed during the visit are documented on the LIC-809D page. Exit interview was held and copies of reports LIC-809, LIC-809C, LIC 809D, and Appeal Rights were discussed and provided to Administrator Armen Markosian.
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Luis DeLeon
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2025
LIC809 (FAS) - (06/04)
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