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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195850251
Report Date: 07/13/2023
Date Signed: 07/13/2023 01:52:15 PM


Document Has Been Signed on 07/13/2023 01:52 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:VALLEY SENIOR CARE LIVING, INCFACILITY NUMBER:
195850251
ADMINISTRATOR:DANIELIAN, KHATCHIKFACILITY TYPE:
740
ADDRESS:8140 MATILIJA AVETELEPHONE:
(310) 666-2392
CITY:VAN NUYSSTATE: CAZIP CODE:
91402
CAPACITY:6CENSUS: 5DATE:
07/13/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Syeta Karapetyan, staffTIME COMPLETED:
02:00 PM
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Licensing Program Analyst (LPA) Emily Peraldi conducted a subsequent unannounced visit to this location. The purpose of this visit was to conduct follow up inspection of the property to ensure that the applicant, Davit Hakobyan has not admitted additional residents until the facility is licensed, per his Plan of Correction dated 06/16/2023.

During the time of the visit, the LPA attempted to contact the applicant via telephone calls and text messages.

At 1:15 p.m., the LPA gained accesses to the property. At 1:18 p.m., the LPA conducted a brief physical plant tour with Staff #1 (S1). At 1:20 p.m., the LPA conducted an interview with S1. At 1:20 p.m., the LPA observed a new resident and conducted an interview with the new resident. No immediate health and safety concerns noted.

During a subsequent visit conducted on 06/16/2023, LPAs Peraldi and Chochian issued and read the Notice of Operation in Violation of Law (NOVL) with applicant, Davit Hakobyan. The LPAs also reminded the applicant that no new residents shall be admitted until the facility is licensed and failure to comply could affect approval of his license.

The applicant was not available to sign the report, however staff is authorized to sign. A copy of the report of provided.
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 593-4493
LICENSING EVALUATOR NAME: Emily PeraldiTELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:
DATE: 07/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/13/2023
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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