565850678-5-8-2026-29-AS-BBAI-DTVR59-20260508124247

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565850678
Report Date: 05/08/2026
Date Signed: 05/08/2026 12:43:06 PM

Document Has Been Signed on 05/08/2026 12:43 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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	FAIRWAYS RESIDENTIAL, THE		FACILITY NUMBER:	565850678
ADMINISTRATOR/ DIRECTOR:	KHACHATRYAN, MARGARITA		FACILITY TYPE:	740
ADDRESS:	2399 LEE STREET		TELEPHONE:	(818) 445-8065
CITY:	SIMI VALLEY	STATE: CA	ZIP CODE:	93065
CAPACITY: 6		CENSUS: 0	DATE:	05/08/2026
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	10:00 AM
MET WITH:	Margarita Khachatryan		TIME VISIT/ INSPECTION COMPLETED:	01:00 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 Analyst (LPA) Brian Balisi conducted a pre-licensing visit to the above noted facility. Upon arrival LPA met with applicant Margarita Khachatryan. The fire clearance was granted for five (5) non-ambulatory residents and one (1) bedridden resident on 10/10/2025 . The facility is one story. At approximately, 10:00 a.m., a physical plant tour was conducted inside and out. The facility has four (4) private bedrooms and one (1) shared bedroom. There are no fire sprinklers in the facility. There is a locked closet inaccessible to residents in care. LPA observed Kitchen knives, sharp objects and first aid kit. The first aid supplies were complete, including a thermometer and a current version of a first aid manual. Medications are planned to be stored here as well. The supply of dishes, utensils, pots, pans and drink ware is adequate. The freezer was maintained at zero degrees Fahrenheit (0F) and the refrigerator was maintained at 40F. The supply of nonperishable food is adequate. There are no pesticides (poisons) or toxins stored in any food storage area or preparation area with utensils. Appliances in the kitchen were clean and all appeared functional at the time of the visit. Trash cans had tight fitting lids. No flies or other vermin were observed. All resident rooms are set up with beds, night stands, lamps, chests of drawers, chairs and closet space. The beds are furnished with comfortable mattress and clean linen, which includes, a mattress pad, top and bottom linens, pillowcases, blanket and a bedspread. Lighting in the rooms appeared adequate. In addition, no bedroom was used as a passageway to another room, bath or toilet. There is no staff room at the facility at this time. All rooms were free of odors. All window screens were clean and maintained in good repair. There is cabinet located in the hallway by room #5 that stored an adequate supply of extra bed and bath linens. There are two (2) bathrooms total. The resident bathroom(s) have a shower with non-skid materials. The toilet and shower have grab bars. The hot water temperature was tested in the bathrooms and the kitchen and was found to be within the range of 105 and 120 degrees Fahrenheit.

NAME OF LICENSING PROGRAM MANAGER: Desaree Perera
NAME OF LICENSING PROGRAM ANALYST: Brian Balisi
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/08/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2026

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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: FAIRWAYS RESIDENTIAL, THE	FACILITY NUMBER: 565850678
	VISIT DATE: 05/08/2026

NARRATIVE

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The common areas were appropriately furnished, and the lighting was adequate. Enough seating for residents in care. There was sufficient space to accommodate both indoor and outdoor activities. There is (1) functioning screened fireplace on site. There is a functioning telephone on the premises. No obstructions were observed inside or out. The facility has a furnace, which is able to heat rooms that residents occupy to a minimum of 68 degrees Fahrenheit; and, they have central air conditioning and are able to cool rooms to a comfortable range, not to exceed 85 degrees Fahrenheit. The emergency exiting plans/sketch are posted throughout. The emergency telephone numbers, and other required postings are posted in the common spaces. The smoke detector and carbon monoxide detectors are hard wired, they were tested and functioned properly during the time of visit. Fire extinguishers were observed fully charged and purchased this year.

There is an attached garage inaccessible to residents in care. The washer and dryer are located in the garage as well. LPA observed (1) storage cabinet in the garage locked and inaccessible. LPA observed cabinet to store cleaning supplies and other toxins. The physical layout does not match the submitted facility sketch. The floor plan labels the garage as an “ADU,” but the garage has not been converted at this time. The applicant will submit an updated facility sketch showing the area as a garage, not an ADU. The applicant was advised to notify the department before starting any future ADU conversion and to submit updated facility sketches and documents for a revised fire clearance. The exterior passageways were clean and clear of any obstructions. There is a covered patio area in the backyard. The LPA observed appropriate furniture for outdoor use. The outside area was observed to be large enough to conduct outdoor activities. There are (3) storage sheds. LPA observed (2) out of (3) to be empty at this time. (1) shed was observed to contain holiday decorations. The LPA observed one (1) self-latching gate. There are no bodies of water on the premises at this time.

Component III was conducted in conjunction with the visit.

This report will be sent to the Centralized Application Bureau (CAB). You will be notified by the CAB Analyst when your license has been approved. You are not allowed to begin operating until you have been notified that your license has been approved by the CAB Analyst. Failure to comply could affect approval of your license.

No corrections required at this time. Exit interview conducted. Report issued and provided to Applicant.

NAME OF LICENSING PROGRAM MANAGER: Desaree Perera
NAME OF LICENSING PROGRAM ANALYST: Brian Balisi
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/08/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2026

LIC809 (FAS) - (06/04)

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