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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195850163
Report Date: 02/21/2024
Date Signed: 02/21/2024 02:05:53 PM


Document Has Been Signed on 02/21/2024 02:05 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:BELLAIRE SENIOR CARE, LLCFACILITY NUMBER:
195850163
ADMINISTRATOR:ELEN KIRAKOSYANFACILITY TYPE:
740
ADDRESS:6523 BELLAIRE AVETELEPHONE:
(818) 856-6980
CITY:NORTH HOLLYWOODSTATE: CAZIP CODE:
91606
CAPACITY:6CENSUS: 6DATE:
02/21/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:21 AM
MET WITH:Erna Gevorgyan,AdministratorTIME COMPLETED:
02:15 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Emily Peraldi and Valeria Conway conducted an unannounced visit to this location for the purpose of delivering Notice of Operation in Violation of Law (NOVL) issued on 02/21/2024. At 11:21 a.m., the LPAs met with staff and explained the reason for the visit. At 11:55 a.m., the Administrator, Erna Gevorgyan arrived at the facility. At 1:21 p.m., LPA Peraldi spoke with Applicant, Eva Terzian telephonically regarding today’s visit.

At 11:22 a.m., LPAs gained entry onto the property and observed six (6) residents and three (3) staff. During the time of the visit, LPA Peraldi had several conversations with the Applicant and the Administrator regarding the current state of the License. The Applicant and Administrator explained that an application for a change of ownership was sent out on 01/22/2024. The LPAs informed the Applicant, and the Administrator that at this time, they are operating unlicensed, and a completed application needs to be submitted in order to be in compliance of section 1569.10 and/or 1569.44 of the Health & Safety Code. The Applicant and the Administrator stated that they will send the LPAs proof of the change of ownership application.

A Notice of Operation in Violation of Law (NOVL) was issued. The Applicant was advised that a retroactive civil penalty of $100 per day per resident shall be assessed on the 16th day from the original date of the notice of Operation in Violation of the Law (February 21, 2024) for the operation of an unlicensed facility. If the operator has not ceased operation or submitted a completed application for licensure within 15 calendar days of the issuance of this notice. On the 16th day from the notice, if the unlicensed operation continues to operate, a $200 per resident per day will be assessed until a completed application is submitted or the operation ceases.

Continued on LIC 809-C
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Emily PeraldiTELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:
DATE: 02/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/21/2024
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


Document Has Been Signed on 02/21/2024 02:05 PM - It Cannot Be Edited

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: BELLAIRE SENIOR CARE, LLC
FACILITY NUMBER: 195850163

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/21/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/08/2024
Section Cited
HSC
1569.10

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HSC: 1569.10 RCFE; license or permit; necessity: No person… corporation... shall operate…conduct, or maintain a residential facility for the elderly in this state without a current valid license or current valid ...This requirement was not met as evidenced by
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Applicant was informed to either relocate residents (in need of care and supervision) to a licensed facility or submit a complete application within 15 calendar days of this date. LPAs advised Applicant that they have 15 calendar days to complete the plan of correction.
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Based on interviews and record review, the Licensee did not comply with the section cited above as the Licensee sold LLC to Applicant without proper new license which poses an immediate health and safety risk to residents in care.
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If uncorrected, civil penalties will be assessed. Applicant stated that application for a change of ownership sent out on 01/22/2024.

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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.
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Emily PeraldiTELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:
DATE: 02/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/21/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3


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: BELLAIRE SENIOR CARE, LLC
FACILITY NUMBER: 195850163
VISIT DATE: 02/21/2024
NARRATIVE
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The Applicant may submit a complete application at the Woodland Hills Adult and Senior Care Regional Office located 21731 Ventura Blvd STE 250, Woodland Hills, CA 91364. The Applicant may go to www.ccld.ca.gov for orientation information. The LPAs reminded the Applicant to not take in additional residents.

Citation was issued per Health and Safety Code. See LIC 809-D included with this report.

Exit interview conducted. Appeal rights and a copy of the report was issued. NOVL issued.
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Emily PeraldiTELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:

DATE: 02/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/21/2024
LIC809 (FAS) - (06/04)
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