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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195850251
Report Date: 09/06/2023
Date Signed: 09/06/2023 11:38:53 AM


Document Has Been Signed on 09/06/2023 11:38 AM - 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: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:0CENSUS: 4DATE:
09/06/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Syeta KarapetyanTIME COMPLETED:
11:45 AM
NARRATIVE
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Licensing Program Analysts (LPAs) Emily Peraldi and Zabel Chochian conducted an unannounced visit to this location for the purpose of notifying applicant, Davit Hakobyan, that the licensure application for this property has been denied by Community Care Licensing’s (CCL) Centralized Applications Bureau, effective August 28, 2023.

At 8:30 a.m., LPAs gained entry onto the property and observed four (4) individuals residing at the facility that require care and supervision. The applicant was not able to meet with LPAs at this property.

At 10:46 a.m., the LPAs spoke with Davit Hakobyan over the telephone. During the telephonic conversation, Davit Hakobyan acknowledged receiving the Department’s application denial letter that was sent via certified mail on August 28, 2023. Mr. Hakopyan was informed that a second Notice of Operation in Violation of Law (NOVL) is served during today’s visit. An initial NOVL was served to Davit Hakobyan on June 16, 2023. During today’s visit, LPAs provided a copy of the Department’s application denial letter for this property.

Per the NOVL, Mr. Hakobyan must relocate all individuals requiring care and supervision by September 26, 2023. It was also explained to Mr. Hakobyan that per Health and Safety Code 1569.16(b), re-submitting an application will not correct today’s citation, as an applicant does not have the right to re-apply for licensure for one year after the Department’s application denial.

Mr. Hakobyan was not available to sign the report, however staff was authorized to sign.

A copy of this report was emailed to Mr. Hakobyan.
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Emily PeraldiTELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:
DATE: 09/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/06/2023
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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Document Has Been Signed on 09/06/2023 11:38 AM - 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: VALLEY SENIOR CARE LIVING, INC
FACILITY NUMBER: 195850251

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/06/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/07/2023
Section Cited
HSC
1569.10

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HSC: 1569.10. RCFE; license or permit; necessity: No person,... or corporation... shall operate,…manage,…or maintain a residential facility for the elderly in this state without a current valid license ...This requirement was not met as evidenced by:
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The Applicant agreed and acknowledged that he shall relocate all individuals requiring care and supervision by September 26, 2023. The Applicant also agreed to provide proof of each individuals relocation site.
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Based on interviews and record review, the Applicant did not comply with the section cited above as four (4) out of four (4) individuals require assistance with aspects of care in activities of daily living, which poses an immediate health and safety risk to individuals 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: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Emily PeraldiTELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:
DATE: 09/06/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/06/2023
LIC809 (FAS) - (06/04)
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