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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195850306
Report Date: 12/22/2025
Date Signed: 12/22/2025 03:16:29 PM

Document Has Been Signed on 12/22/2025 03:16 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:AAA JERUSALEM STARSFACILITY NUMBER:
195850306
ADMINISTRATOR/
DIRECTOR:		SOHEILA NOROOZIFACILITY TYPE:
740
ADDRESS:5945 CAPISTRANO AVETELEPHONE:
(818) 888-1706
CITY:WOODLAND HILLSSTATE: CAZIP CODE:
91367
CAPACITY: 6CENSUS: 6DATE:
12/22/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:10 AM
MET WITH:Kristina AdamyanTIME VISIT/
INSPECTION COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) Angela Barutyan arrived at the facility unannounced to conduct a required annual visit at 11:10AM. LPA met with staff and Administrator Kristina Adamyan upon arrival. Entrance interview conducted.

At 11:12AM, the LPA along with staff and Administrator toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations.
KITCHEN: The LPA inspected the kitchen/food service area at 11:12AM. Kitchen appliances appeared clean and were in operable condition at the time of the visit. The facility had a sufficient supply of perishable and non-perishable food. At 11:13AM, LPA observed the knives stored accessible to residents as the lock on the drawer was inoperable. Administrator stated that the lock will be replaced. LPA observed locked and inaccessible cleaning solutions under the sink. Fire extinguisher by the kitchen area was fully charged and last purchased on 12/01/2025. At 11:18AM, LPA observed a fruit fly infestation in the pantry. Administrator stated they have hired a monthly exterminator service and that there are fruit fly traps by the kitchen sink. LPA advised to install fruit fly traps in the pantry as well. Administrator stated they will call an exterminator to address the fruit flies.
BEDROOMS: There are five (5) resident bedrooms; four (4) are designated for single-use and one (1) is designated for shared-use. LPA observed resident bedrooms to be furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting. At 11:27AM, LPA observed the direct exit in Bedroom #3 obstructed with a metal pipe in the sliding door, preventing it from opening. Staff removed the metal pipe immediately. Bedroom #3 has a bedridden fire clearance, and LPA explained that the direct exit cannot be obstructed due to fire clearance and immediate health/safety hazards. Report Continued on LIC809-C.
NAME OF LICENSING PROGRAM MANAGER: Kristin Heffernan
NAME OF LICENSING PROGRAM ANALYST: Angela Barutyan
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 12/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/22/2025
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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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.

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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: AAA JERUSALEM STARS
FACILITY NUMBER: 195850306
VISIT DATE: 12/22/2025
NARRATIVE
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 At 11:35AM, LPA observed Bedroom #4 with a heavily stained mattress with no mattress cover, rubber sheeting, or pads. The mattress had one sheet that was lifted in the corners with the mattress exposed. Administrator stated the mattress will be replaced and a waterproof cover will be installed on the mattress. At 11:43AM, LPA observed the vinyl floorboards in Bedroom #4 to be peeling and a potential fall hazard. LPA observed a locked staff room in the hallway. Auditory exit alarms were functional.

RESTROOMS: There are four (4) restrooms of which three (3) are designated for resident-use and one (1) is designated for staff and visitor use. At 11:27AM, LPA observed the slip-resistant mat in the hallway bathroom to be in unsanitary and inoperable condition. Administrator stated the mat will be replaced. At 11:41AM, LPA observed the restroom attached to Bedroom #4 to not have appropriately running hot water, the toilet lid removed and on the floor, toilet in unsanitary condition, restroom not stocked with necessary supplies such as toilet paper and a trash bag in the trash can, the trash can with the lid removed and on the toilet, and the sink in unsanitary condition. Staff repaired the hot water which LPA measured from 11:56AM-12:02PM to reach 105.1 degrees F. At 12:31PM, LPA observed the hallway restroom with an unsanitary sink. Hot water temperatures were measured in resident restrooms and were between 105.1-106.5 degrees F, which is within the required range. Restrooms were equipped with functional grab bars.

OUTDOOR AREA: The backyard has a covered outdoor area equipped with furniture for resident use. At 12:38PM, LPA observed a shed in the backyard containing extra mattresses and beds with a nonfunctional lock. LPA observed the mattresses in disrepair and unsanitary as they were covered in dirt. Administrator stated that the mattresses were meant to be thrown away and are not for resident-use. There is a side gate which was observed to self-latch. At 12:40PM, LPA observed the emergency exit passageway obstructed with trash bins and a ladder. Staff removed the obstructions during the visit. No bodies of water noted.

COMMON AREAS: At the time of the visit, living room and family room furniture were observed to be in good condition. There is one (1) fireplace which was observed adequately screened. The facility maintained a comfortable temperature. At 12:41PM, LPA observed the window screens for the sliding exit doors in the family room and Bedroom #4 to be uninstalled and removed from its tracks. Administrator stated they did not know why the screens were removed and stated that they will be reinstalled. At 12:52PM, smoke detectors and carbon monoxide detectors were tested and were operational at the time of the visit. LPA observed required postings throughout the common spaces. Report Continued on LIC809-C.
NAME OF LICENSING PROGRAM MANAGER: Kristin Heffernan
NAME OF LICENSING PROGRAM ANALYST: Angela Barutyan
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2025
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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: AAA JERUSALEM STARS
FACILITY NUMBER: 195850306
VISIT DATE: 12/22/2025
NARRATIVE
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GARAGE: LPA observed a locked garage adjacent to the kitchen that contained a washer and dryer, additional refrigerator/freezer, additional food and supplies, and an office area.

INTERVIEWS: During today’s visit, LPA interviewed four (4) residents and three (3) staff.

MEDICATION REVIEW: Will be reviewed during annual continuation.

RECORD REVIEW: Will be reviewed during annual continuation.

INFECTION CONTROL/EMERGENCY DISASTER PLANNING: Will be reviewed during annual continuation.

Due to time constraints, the annual inspection will be finished on a later date.

Pursuant to Title 22, CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D). Civil penalty was issued in the amount of $500 for fire clearance violation. Administrator was informed that failure to correct deficiencies may result in additional civil penalties.

Exit interview conducted, report issued, and appeal rights provided.
NAME OF LICENSING PROGRAM MANAGER: Kristin Heffernan
NAME OF LICENSING PROGRAM ANALYST: Angela Barutyan
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/22/2025 03:16 PM - It Cannot Be Edited


Created By: Angela Barutyan On 12/22/2025 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: AAA JERUSALEM STARS
FACILITY NUMBER: 195850306

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/22/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87202(a)
Fire Clearance
(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above as the direct exit for Bedroom #3, which has fire clearance for bedridden, was obstructed with a metal pipe preventing it from opening. This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/23/2025
Plan of Correction
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Staff removed the metal pipe during the visit. POC is cleared.
Type A
Section Cited
CCR
87309(a)
Storage Space and Access
(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above as the lock for the knife drawer was non-functional resulting in knives being stored accessible. This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/23/2025
Plan of Correction
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Administrator stated the lock on the drawer will be replaced. Administrator will submit proof to CCLD by the due date.
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:
Angela Barutyan
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 12/22/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/22/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/22/2025 03:16 PM - It Cannot Be Edited


Created By: Angela Barutyan On 12/22/2025 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: AAA JERUSALEM STARS
FACILITY NUMBER: 195850306

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/22/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above as the vinyl flooring in Bedroom #4 was peeling, restroom sinks were in unsanitary condition, and the toilet lid in Bedroom #4's restroom was not in good repair which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/12/2026
Plan of Correction
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Administrator stated that restroom sinks will be cleaned and maintained in sanitary condition, flooring will be patched so it is no longer a trip hazard, and the toilet lid will be repaired. Administrator will submit proof to CCLD by the due date.
Type B
Section Cited
CCR
87303(c)
Maintenance and Operation
(c) All window screens shall be clean and maintained in good repair.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above as two (2) window screens for the sliding doors in the living room and Bedroom #4 were uninstalled which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/29/2025
Plan of Correction
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Administrator stated that the screens will be reinstalled onto their tracks. Administrator will submit proof to CCLD by the due date.
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:
Angela Barutyan
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 12/22/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/22/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/22/2025 03:16 PM - It Cannot Be Edited


Created By: Angela Barutyan On 12/22/2025 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: AAA JERUSALEM STARS
FACILITY NUMBER: 195850306

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/22/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(e)(5)(A)
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. (A) All slip-resistant mats, strips, or flooring shall be in good repair and maintain slip-resistant properties.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above as the slip-resistant mat in the hallyway restroom was in disrepair which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/29/2025
Plan of Correction
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Administrator stated the mat will be replaced. Administrator will submit proof to CCLD by the due date.
Type B
Section Cited
CCR
87303(f)(1)
Maintenance and Operation
(f) All waste shall be located, stored, and disposed of in a manner that will not transmit communicable diseases or odors, pose a risk to health and safety, or provide a breeding place or food source for insects or rodents. (1) All containers storing waste shall be in good repair, free of leaks, and emptied in a timely manner.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above as the trash can in Bedroom #4's restroom was in disrepair with a broken lid and no trash bag which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/29/2025
Plan of Correction
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Administrator stated they will replace the trash can. Administrator will submit proof to CCLD by the due date.
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:
Angela Barutyan
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 12/22/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/22/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/22/2025 03:16 PM - It Cannot Be Edited


Created By: Angela Barutyan On 12/22/2025 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: AAA JERUSALEM STARS
FACILITY NUMBER: 195850306

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/22/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87307(a)(3)(C)
Personal Accommodations and Services
(C) Clean linen, including blankets, bedspreads, top bed sheets, bottom bed sheets, pillow cases, mattress pads, bath towels, hand towels and wash cloths. The quantity shall be sufficient to permit changing at least once per week or more often when indicated to ensure that clean linen is in use by residents at all times. The linen shall be in good repair. The use of common wash cloths and towels shall be prohibited.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation and interview, the licensee did not comply with the section cited above as the mattress in Bedroom #4 was in unsanitary condition and not equipped with mattress pads and appropriate sheets which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/05/2026
Plan of Correction
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2
3
4
Administrator stated they will replace the mattress and equip it with appropriate sheets. Administrator will submit proof to CCLD by the due date.
Type B
Section Cited
CCR
87555(b)(27)
General Food Service Requirements
(b) The following food service requirements shall apply: (27) All kitchen areas shall be kept clean and free of litter, rodents, vermin and insects.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and interview, the licensee did not comply with the section cited above as the kitchen had an active fruit fly infestation in the pantry which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/12/2026
Plan of Correction
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2
3
4
Administrator installed a fruit fly trap in the pantry during the visit. Administrator stated they will service an exterminator to address the fruit flies. Administrator will submit proof to CCLD by the due date.
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:
Angela Barutyan
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 12/22/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/22/2025


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