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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195850239
Report Date: 03/01/2025
Date Signed: 03/01/2025 02:49:27 PM

Document Has Been Signed on 03/01/2025 02:49 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:SILVER LIGHT CAREFACILITY NUMBER:
195850239
ADMINISTRATOR/
DIRECTOR:		KHACHATRYAN, ELBAFACILITY TYPE:
740
ADDRESS:8201 VANTAGE AVENUETELEPHONE:
(747) 228-4111
CITY:NORTH HOLLYWOODSTATE: CAZIP CODE:
91605
CAPACITY: 6CENSUS: 6DATE:
03/01/2025
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:30 AM
MET WITH:Keyna NkumbulaTIME VISIT/
INSPECTION COMPLETED:
02:50 PM
NARRATIVE
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Licensing Program Analyst (LPA) Trevor Byrne arrived to the facility at 10:30 AM to conduct an unannounced Case Management – Other inspection at the facility today. LPA met with facility staff member Keyna Nkumbula (S1) who contacted the facility Administrator Elba Khachatryan entrance interview conducted and the reason for the visit was explained. The Administrator stated that they were unable to come to the facility at the time of the visit but has designated S1 to receive this report on their behalf.

During today’s visit between 10:32 AM and 1:00 PM, LPA conducted a physical plant tour, conducted a medication audit for three (3) residents, conducted a brief file review for six (6) residents, interviewed six (6) residents, one (1) staff member, and attempted to interview one (1) guest. The following was observed.

KITCHEN: The LPA observed the kitchen area to be clean. Kitchen appliances appeared to be in operable condition. The facility has a sufficient supply of two (2) days perishable and seven (7) days non-perishable food.

BEDROOMS: LPA observed three (3) resident bedrooms. All bedrooms were observed to be furnished appropriately.

BATHROOMS: LPA observed one (1) common resident bathroom. The bathroom appeared to be clean and in good repair.

Continued on LIC 809C.
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Trevor Byrne
LICENSING EVALUATOR SIGNATURE: DATE: 03/01/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/01/2025
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 5
Document Has Been Signed on 03/01/2025 02:49 PM - It Cannot Be Edited


Created By: Trevor Byrne On 03/01/2025 at 01:54 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: SILVER LIGHT CARE
FACILITY NUMBER: 195850239

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/01/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/01/2025
Section Cited
CCR
87309(a)

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87309 Storage Space and Access
(a) ... the licensee shall ensure that disinfectants, cleaning solutions... and other similar items... are in locked storage...
This requirement is not met as evidenced by:
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Facility staff secured the garage at the time of the visit. POC cleared.
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Based on observation the licensee did not comply with the section cited above as the garage containing cleaning and laundry chemicals was left unsecured which poses an immediate safety risk to clients in care.
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Type B
03/01/2025
Section Cited
CCR87468.2(a)(14)

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87468.2 Additional Personal Rights...
(a) In addition to the rights...
(14) To reasonable accommodation of their individual needs and preferences in all aspects of life in the facility...
This requirement is not met as evidenced by:
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Facility staff agreed to do the resident's laundry at the time of the visit. POC cleared.
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Based on observation and interview the licensee did not comply with the section cited above as one resident did not have their laundry done in a timely manner which left them with no clean pants or shorts to wear which poses a potential personal rights risk to clients in care.
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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:Kasandra Lopez
LICENSING EVALUATOR NAME:Trevor Byrne
LICENSING EVALUATOR SIGNATURE:
DATE: 03/01/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/01/2025


LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 03/01/2025 02:49 PM - It Cannot Be Edited


Created By: Trevor Byrne On 03/01/2025 at 02:03 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: SILVER LIGHT CARE
FACILITY NUMBER: 195850239

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/01/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/15/2025
Section Cited
CCR
87465(h)(6)(D)

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87465 Incidental Medical and Dental Care
(h) The following...shall apply...
(6) The licensee shall be responsible for assuring that a record...is maintained... and includes:
(D) The date filled.
This requirement is not met as evidenced by:
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Licensee will submit an accurate CSMDR sheet for the three residents to CCLD no later than POC due date.
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Based on record review the licensee did not comply with the section cited above as three residents CSMDR sheets had the incorrect dates of when the perscriprion was filled which poses a potential health risk to clients in care.
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Type B
03/15/2025
Section Cited
CCR87465(a)(4)

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87465 Incidental Medical and Dental Care
(a) A plan for incidental medical and dental care shall be developed by each facility...by compliance with the following:
(4)The licensee shall assist residents with self-administered medications as needed.
This requirement is not met as evidenced by:
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Licensee will submit either, their plan on how they will ensure medications are given as perscribed or proof of medication refusal for the identified resident to CCLD no later than POC due date.
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Based on record review the licensee did not comply with the section cited above as one resident's medication was not administered and staff were unable to proide proof of medication refusal which poses a potential health risk to clients in care.
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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:Kasandra Lopez
LICENSING EVALUATOR NAME:Trevor Byrne
LICENSING EVALUATOR SIGNATURE:
DATE: 03/01/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/01/2025


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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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: SILVER LIGHT CARE
FACILITY NUMBER: 195850239
VISIT DATE: 03/01/2025
NARRATIVE
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COMMON AREAS / OUTDOOR AREAS: LPA observed the common areas of the facility to be clean and in good repair. LPA observed cameras located throughout the outdoors of the facility. At 10:43 AM LPA observed the garage door to be open and unsecured. LPA observed the garage to contain bleach and other cleaning chemicals accessible to clients in care. Additionally, the garage was observed to contain additional food and water supplies. LPA advised the Administrator via telephone call that they were previously cited for a violation of CCR 87309(a) on 10/22/2024. LPA advised Administrator that a civil penalty in the amount of $250 will be assessed due to a repeat violation of the same regulation within a 12-month period.

INTERVIEWS: LPA interviewed six (6) residents. All residents interviewed stated that staff members are always present on site at the facility. All residents interviewed stated that they facility provides them with ample amounts of food and provides meals at appropriate times. One (1) resident interviewed (R1) stated that they had no clean pants or undergarments to wear. This resident stated that their laundry is done once a week. LPA interviewed S1, S1 stated that they do R1’s laundry once a week as it has to be done separately from other resident’s laundry. S1 retrieved a clean pair of undergarments for R1 and confirmed that they would do a load of laundry for R1 at the time of the visit. LPA informed S1 that the garage of the facility was unlocked and accessible to clients in care. S1 secured the garage at the time of the visit. During the visit LPA observed a guest (G1) who stated they were there to visit S1.

MEDICATION REVIEW: LPA reviewed medications for three (3) of six (6) residents. LPA observed all three (3) resident’s centrally stored medication and destruction record sheets (CSMDR) to contain the incorrect dates for medications filled. LPA observed three (3) residents to have medications stored in their medication boxes that were not listed on their CSMDR. LPA observed one (1) resident’s medication to not be administered as prescribed. LPA asked S1 to clarify the discrepancy. S1 stated that the medication arrived yesterday while staff #2 (S2) was on shift. S2 informed S1 that the resident refused to take the medication, and they logged the refusal. S1 attempted to find the refusal log but was unable to provide LPA with proof of medication refusal.

During today’s visit LPA also discussed the staff schedule with S1 who confirmed that S1 and S2 are the primary staff at the facility and there is 24-hour presence of staff at the facility at all times. A current LIC 500 was not available, but the Administrator stated that they would email a copy of the LIC 500 to LPA later today. Continued on LIC 809C.
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Trevor Byrne
LICENSING EVALUATOR SIGNATURE:

DATE: 03/01/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/01/2025
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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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: SILVER LIGHT CARE
FACILITY NUMBER: 195850239
VISIT DATE: 03/01/2025
NARRATIVE
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Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies and civil penalty were cited (refer to LIC 809-D): The Administrator was unable to come to the facility at the time of the inspection but has designated S1 to sign on their behalf. This report was read to the Administrator via telephone call. Exit interview conducted and copy of the report was issued and appeal rights provided.
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Trevor Byrne
LICENSING EVALUATOR SIGNATURE:

DATE: 03/01/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/01/2025
LIC809 (FAS) - (06/04)
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