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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195850075
Report Date: 11/19/2025
Date Signed: 11/21/2025 01:55:34 PM

Document Has Been Signed on 11/21/2025 01:55 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 N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:A-1 BOARDING CAREFACILITY NUMBER:
195850075
ADMINISTRATOR/
DIRECTOR:		HOVHANNES ISPIRYANFACILITY TYPE:
740
ADDRESS:6511 BONNER AVE.TELEPHONE:
(818) 691-3146
CITY:N. HOLLYWOODSTATE: CAZIP CODE:
91606
CAPACITY: 6CENSUS: 6DATE:
11/19/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:36 AM
MET WITH:Erna Gevorgyan, StaffTIME VISIT/
INSPECTION COMPLETED:
07:00 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) Christine Yee conducted an unannounced Annual Inspection visit and used the CARE inspection Tool to conduct the visit. LPA Yee was let into the home by Ani Malkhasyan, Staff. Erna Gevorgyan, Administrator designee was conducted by telephone and she arrived at 11:06am to conduct the visit. The reason for today's visit was provided.

The facility is a single storey family home consisting of a living room, a dining room, a kitchen, 4 bedrooms, 2 private bathrooms and a common bathroom. Located in the back of the property is an ADU with a separate address - 6509 Bonner Avenue, and is not part of the facility operations. The facility is fire cleared for 1 AMBULATORY, 4 NON-AMBULATORY and 1 BEDRIDDEN resident. Bedroom #2 or Bedroom #3 approved for 1 bedridden use. The facility is approved for 6 hospice waivers.

On today's visit, the entire CARE Inspection tool was reviewed, 6 resident and 6 staff files were reviewed and the Emergency Disaster Preparedness Plan was reviewed. The following was observed:
  • Bedrooms #1 and Bedroom #2 are furnished with 2 beds, 2 night stands, 2 lamps, 2 chairs and a built in closet. No dressers were observed. The left bed in bedroom #2 was equipped with a full bed rail due to resident previously on hospice but has since being discharged and the right bed equipped with a half bed rail. Bed rails need to be removed. There is no physicians order for the use of the bed rails.
  • Bedroom #3 is furnished with 2 beds, 2 chairs, 2 lamps, 2 night stands, 1 built in closet and a shared dresser. The wall needs to be painted due to the resident peeling off the paint each time it is painted.

continued on LIC809-C
NAME OF LICENSING PROGRAM MANAGER: Kristin Heffernan
NAME OF LICENSING PROGRAM ANALYST: Christine Yee
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 11/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/20/2025
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 7
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 7
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: A-1 BOARDING CARE
FACILITY NUMBER: 195850075
VISIT DATE: 11/19/2025
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
26
27
28
29
30
31
32
Page 2.
  • Located inside Bedroom #3 is a private bathroom, equipped with a walk in shower, a toilet and a sink. Grab bars were observed. No slip resistant mat was observed. Water temperature was tested and read 116.5 degrees Fahrenheit.
  • Bedroom #4 is currently not furnished and is used for storage. Located inside is a private bathroom equipped with a shower stall, a toilet and a sink. Grab bars were observed. No slip resistant mats were observed.
  • the living room and dining room were furnished with the appropriate furniture for it's designated use.
  • Extra bed linens and towels were observed in the linen closet.
  • The kitchen is equipped with a refrigerator, a stove, a dishwasher, a microwave and a water cool. Plenty of perishable foods for a minimum of 2 days and non-perishable foods for a minimum of 7 days were observed. The Licensee will supplement the non-perishable foods with additional proteins. Medications are stored in a locked kitchen cupboard.
  • The common bathroom is equipped with a walk in shower, a toilet, a sink, a shower chair, grab bars and a toilet riser. No slip resistant mats were observed, Water temperature was tested and read 118.9 degrees Fahrenheit. Hygiene products are stored in the locked bathroom cabinets.
  • The auditory devices on the outside exiting doors were operational.
  • The only fire extinguisher, purchased on 12/10/24 is located by the front door.
  • The hard wired smoke detectors located in the resident bedrooms and the combination smoke/carbon monoxide detector located in the living room and resident hallway were tested and were operational.
  • The first aid kit contained the required scissors, tweezer and thermometer. No first aid manual was observed on today's visit
  • The required postings were observed but the licensee needs to purchase a current labor poster.
  • The laundry room located in the back was observed with a washer and dryer.
  • Also located by the laundry room is a storage shed.
  • A long ramp for wheelchair use to exit from the living room, bedroom #3 and bedroom #2, separates the back property utilized by the ADU.
  • No bodies of water was observed on the property
  • Located in the front is a gazebo furnished with seating and a table for outside activities.


Continued on LIC809-C
NAME OF LICENSING PROGRAM MANAGER: Kristin Heffernan
NAME OF LICENSING PROGRAM ANALYST: Christine Yee
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 11/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2025
LIC809 (FAS) - (06/04)
Page: 3 of 7
Document Has Been Signed on 11/21/2025 01:55 PM - It Cannot Be Edited


Created By: Christine Yee On 11/19/2025 at 06:38 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
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: A-1 BOARDING CARE
FACILITY NUMBER: 195850075

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/19/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(e)(5)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (5) Slip-resistant mats, strips, or flooring shall be used in all bathtub and shower floors.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in 3 out of 3 bathrooms inspected, there were no slip resistant mats in the 2 private bathrooms or in the common bathrooms ons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/27/2025
Plan of Correction
1
2
3
4
The Licensee will provide or purchase a slip resistant mat for each of the bathrooms and provide evidence by 11/27/25 that the deficiency has been corrected.
Type B
Section Cited
CCR
87307(a)(3)(E)
Equipment and supplies necessary for personal care and maintenance of adequate hygiene practice shall be readily available to each resident. The resident may provide the following items; however, if the resident is unable or chooses not to provide them, the licensee shall assure E) Portable or permanent closets and drawer space in the bedrooms for clothing and personal belongings. A minimum of eight (8) cubic feet (.743 cubic meters) of drawer space per resident shall be provided.

This requirement is not met as evidenced by: Residents in bedroom #1 and bedroom #2 are not provided with a dresser. Built in shelves in the closet are used in lieu of dressers.
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in 2 out of 3 rooms toured, reveal that the 2 residents in bedroom #1 and bedroom #2 are not provided with a dresser that meets Title 22 requirements for their use which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/27/2025
Plan of Correction
1
2
3
4
The Licensee will provide the required dressers that meets Title 22 requiremets for residents' use in bedroom #1 and bedroom #2 snd provide evidence that the deficiency has been corrected by 11/27/25
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Kristin Heffernan
NAME OF LICENSING PROGRAM MANAGER:
Christine Yee
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 11/20/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/20/2025


LIC809 (FAS) - (06/04)
Page: 4 of 7
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: A-1 BOARDING CARE
FACILITY NUMBER: 195850075
VISIT DATE: 11/19/2025
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
26
27
28
29
30
31
32
Page 3.
  • The trash cans normally stored in the front yard were observed on the street for trash pickup. Trash cans were in good condition.
  • Per tour of the front yard, along the sides of the home and backyard, the outside areas were clean and well maintained.



The Annual Inspection visit was initiated on 11/19/25, but due to laptop issues, a partial report was generated but could not completed for delivery on the date of the site visit. The Report and citations were .completed on 11/20/25 and emailed to the Administrator Designee, Erna Gevorgyan, after telephone contact for her signature.


Deficiencies were cited under California Code of Regulations, Title 22, Division 6, Chapter 8. Any deficiencies not cited on today's visit will be cited on a return visit.

Exit interview was conducted, Appeals Rights discussed and a copy was provided.
NAME OF LICENSING PROGRAM MANAGER: Kristin Heffernan
NAME OF LICENSING PROGRAM ANALYST: Christine Yee
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 11/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2025
LIC809 (FAS) - (06/04)
Page: 5 of 7
Document Has Been Signed on 11/21/2025 01:55 PM - It Cannot Be Edited


Created By: Christine Yee On 11/20/2025 at 01:43 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
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: A-1 BOARDING CARE
FACILITY NUMBER: 195850075

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/19/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(a)(8)(A)
(a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (8) If a facility has no medical unit on the grounds, a complete first aid kit shall be maintained and be readily available in a specific location in the facility. The kit shall be a general type approved by the American Red Cross, or shall contain at least the following: (A) A current edition of a first aid manual approved by the American Red Cross, the American Medical Association or a state or federal health agency.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above as no first aid manual was observed on todya's viisit, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/27/2025
Plan of Correction
1
2
3
4
The Licensee will purchase a fiirst aid manual approved by the American Red Cross, the American Medical Association or a state or federal health agency and maintain at the facility. Evidence that the deficiency has been corrected will be provided to the Department by 11/27/25.
Type B
Section Cited
CCR
87608(a)(3)
Postural Support - (a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions. 3) A written order from a physician indicating the need for the postural support shall be maintained in the resident’s record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in 2 out 6 beds observed, the right bed in bedroom #2 and the right bed in bedroom #3 were observed equipped with half bedrails and there are no written orders in the residents' file from a physician to indicate the need for the postural support which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/27/2025
Plan of Correction
1
2
3
4
The Licensee will remove the half bed rails observed on the beds noted above or obtain a written physician order to support the residents' need for the use of half bed rails. The written order must be maintained in the residents' file. Evidence that the bed rails were removed or a written physician's order was obtained for the need for the use of the bed rails will be provided to the Department by 11/27/25.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Kristin Heffernan
NAME OF LICENSING PROGRAM MANAGER:
Christine Yee
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 11/20/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/20/2025


LIC809 (FAS) - (06/04)
Page: 6 of 7
Document Has Been Signed on 11/21/2025 01:55 PM - It Cannot Be Edited


Created By: Christine Yee On 11/20/2025 at 02:19 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
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: A-1 BOARDING CARE
FACILITY NUMBER: 195850075

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/19/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87608(a)(5)(B)
Postural Supports (a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions: (5) Under no circumstances shall postural supports include tying, depriving, or limiting the use of a resident's hands or feet. (B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and interview with Administrator Designee, the licensee did not comply with the section cited above in 1 out of 6 resident beds observed, the left bed in bedroom #2 was observed with a full bed rail in use. The resident was formerly on hospice but has been discharged which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/27/2025
Plan of Correction
1
2
3
4
The Licensee will remove the full bed rail from the Left bed in bed room #2 or submit a written request for an exception to use the full bed rail, from the Department. A Physician 's written order, medical assessment, the reason for the need of a full bed rail, support letters from physician, family, friends will be provided with the written exception request for consideration by 11/27/25.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Kristin Heffernan
NAME OF LICENSING PROGRAM MANAGER:
Christine Yee
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 11/20/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/20/2025


LIC809 (FAS) - (06/04)
Page: 7 of 7