<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850569
Report Date: 04/17/2025
Date Signed: 04/17/2025 11:49:50 AM

Document Has Been Signed on 04/17/2025 11:49 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:PEACEFUL PINES SENIOR LIVING CORPFACILITY NUMBER:
565850569
ADMINISTRATOR/
DIRECTOR:		KAPIKYAN, ANDRANIKFACILITY TYPE:
740
ADDRESS:321 ROYAL AVETELEPHONE:
(805) 624-8993
CITY:SIMI VALLEYSTATE: CAZIP CODE:
93065
CAPACITY: 6CENSUS: 6DATE:
04/17/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:15 AM
MET WITH:Jessy PhiriTIME VISIT/
INSPECTION COMPLETED:
12:00 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) Brian Balisi conducted an unannounced Case Management - Deficiencies visit in conjunction with a complaint visit (Complaint control # 29-AS-20250224090712). LPA met with staff ane explained the reason for the visit. Licensee Andranik Kapikyan was contacted and stated they could not be onsite at this time. Kapikyan stated staff Jessy Phiri can sign in their place. The purpose of this visit is to issue citations for deficiencies observed during the complaint investigation which were not related to the complaint.
Upon arriving to the facility LPA was unable to access front door due to locked perimeter gate. LPA pressed doorbell on the gate and was greeted by staff and allowed entry to front entrance. LPA’s records review revealed there is no approved fire clearance for a locked perimeter.

During the investigation, records review and interviews conducted revealed on 02/20/2025 at approx. 07:30 p.m. Resident #1 (R1) was brought to the front of the facility at R1’s request when they stated they were being picked up by a family member, however staff did not make any attempts to contact the family / responsible party of R1 to ensure proper arrangements were made for R1 to vacate the facility safely and in a timely manner. R1 was outside of the facility for an extended period of time until police arrived, which resulted in R1 returning to the facility.

The following deficiencies were observed (See LIC 809-D) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. An immediate Civil Penalty for a fire clearance violation is assessed in the amount $500. Administrator was informed that additional civil penalties might be assessed based on Health and Safety Code 1569.49(e) and 1569.49(f).

Exit interview conducted, appeal rights discussed and copy of reports issued.
NAME OF LICENSING PROGRAM MANAGER: Desaree Perera
NAME OF LICENSING PROGRAM ANALYST: Brian Balisi
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/17/2025
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 3
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)
Page: 2 of 3
Document Has Been Signed on 04/17/2025 11:49 AM - It Cannot Be Edited


Created By: Brian Balisi On 04/17/2025 at 11:12 AM
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
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: PEACEFUL PINES SENIOR LIVING CORP
FACILITY NUMBER: 565850569

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/17/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/18/2025
Section Cited
CCR
87705(f)(2)

1
2
3
4
5
6
7
The licensee shall ensure that the fire clearance includes approval of locked exterior doors or perimeter fence gates... to unlock exterior doors or perimeter fence gates. This requirement was not met as evidenced by:
1
2
3
4
5
6
7
Licensee agreed to have key lock replaced and provide a photo to LPA via email by COB 04/18/2025.
8
9
10
11
12
13
14
Based on observation and records review, the licensee did not comply with the section cited above as LPA observed a locked gate and no approved fire clearance on file, which poses an immediate health, safety and personal rights risk to residents in care.
8
9
10
11
12
13
14
Type B
04/25/2025
Section Cited
CCR87468.1(a)(2)

1
2
3
4
5
6
7
To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement was not met as evidenced by:
1
2
3
4
5
6
7
Licensee agreed review section cited and provide a statement of understanding to LPA via email by COB 04/25/2025.
8
9
10
11
12
13
14
Based on interviews and records review, the licensee did not comply with the section cited above as R1 was moved to the exterior of the facility along with their belongings for an extended period of time, which poses a potential health, safety and personal rights risk to residents in care.
8
9
10
11
12
13
14
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Desaree Perera
NAME OF LICENSING PROGRAM MANAGER:
Brian Balisi
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/17/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/17/2025


LIC809 (FAS) - (06/04)
Page: 3 of 3