195850327-6-10-2025-29-AS-QHUH-DHHUB5-20250610152545

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 195850327
Report Date: 06/10/2025
Date Signed: 06/10/2025 03:26:05 PM

Document Has Been Signed on 06/10/2025 03:26 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:	FARMDALE VILLA, INC.		FACILITY NUMBER:	195850327
ADMINISTRATOR/ DIRECTOR:	PARANDZEM KONSTANYAN		FACILITY TYPE:	735
ADDRESS:	6237 FARMDALE AVENUE		TELEPHONE:	(818) 620-0955
CITY:	NORTH HOLLYWOOD	STATE: CA	ZIP CODE:	91606
CAPACITY: 6		CENSUS: 6	DATE:	06/10/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	12:36 PM
MET WITH:	Parandzem Kostanyan - Licensee		TIME VISIT/ INSPECTION COMPLETED:	03:30 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Quoc Huynh arrived at the facility unannounced to conduct a required annual inspection. LPA arrived at the facility at 12:36PM and met with the facility Licensee Parandzem Kostanyan and House Manager/Administrator Yuliya Asatryan and explained the purpose of the visit. Entrance interview conducted. LPA Huynh, Licensee, and Administrator conducted a tour of the physical plant at 12:39PM to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The facility is a Regional Center Level 3 one story residential home. The following was observed: KITCHEN: Knives and other sharps are stored inaccessible in a locked drawer near the pantry and below the drawer is a locked cabinet containing cleaning supplies and laundry detergent. Medications were located inaccessible in an above cabinet. Laundry machines were observed to be operational during the visit. The pantry contained non-perishable foods as well as emergency food and water. The facility has enough supply of perishable and non-perishable food. Kitchen appliances were in operable condition. Freezer and refrigerator were stocked with a variety of foods and labeled. Licensee stated they replenish foods every week. Cleaning supplies were stored under the sink and remained locked at all times. Report Continued on LIC 809-C

NAME OF LICENSING PROGRAM MANAGER: Kristin Heffernan
NAME OF LICENSING PROGRAM ANALYST: Quoc Huynh
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 06/10/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/10/2025

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 4

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.

LIC809 (FAS) - (09/23)

Page: 2 of 4

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: FARMDALE VILLA, INC.	FACILITY NUMBER: 195850327
	VISIT DATE: 06/10/2025

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

COMMON AREAS: At the time of the visit, living room and dining room furniture was observed to be in good condition. The facility maintained a comfortable temperature throughout the visit. The fire extinguisher was fully charged and serviced on 12/04/2024. The LPA observed required postings between the dining room table and kitchen. Sufficient lighting and night lights were observed throughout the facility.

BEDROOMS: The facility has six (6) bedrooms: one (1) staff bedroom, one (1) shared resident bedroom, and three (3) private resident bedrooms. All resident bedrooms had a direct exit to the outside and Bedroom #3 was approved for bedridden residents. Bedrooms were furnished appropriately with sufficient lighting and each room contained extra linens in the closet.

BATHROOMS: There are two (2) shared bathrooms, both located in separate hallways. Bathrooms were observed to be in clean condition with grab bars and non-skid mats available. A sufficient amount of soap and paper products were supplied in each restroom with extra hygiene products and cleaning supplies locked under the sinks. Hot water temperature was measured in both bathrooms at 116.6 degrees F, which is within the required range.

OUTDOOR AREA: The backyard had a ramp and shaded patio equipped with outdoor furniture in good condition for residents’ use. There are two side gates with a self-latching mechanism for residents and staff to evacuate in an emergency. The front yard had a driveway with both a manual and remote gate, with an additional gate for everyday use. LPA Huynh observed a shed which contained general storage. There was an ADU that was fenced off and is occupied by the House Manager. No obstructions or safety hazards were noted.

RECORDS: Record review began at 1:12PM. Six (6) resident records were reviewed for, but not limited to care plans, medical records, admissions agreement, and consent forms. All records were in order. Four (4) personnel records were reviewed for, but not limited to health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All files were in order.

Report Continued on LIC 809-C

NAME OF LICENSING PROGRAM MANAGER: Kristin Heffernan
NAME OF LICENSING PROGRAM ANALYST: Quoc Huynh
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 06/10/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/10/2025

LIC809 (FAS) - (06/04)

Page: 3 of 4

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: FARMDALE VILLA, INC.	FACILITY NUMBER: 195850327
	VISIT DATE: 06/10/2025

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

INFECTION CONTROL/EMERGENCY DISASTER PLAN: LPA reviewed the facility’s infection control plan and emergency disaster plan. Both documents were observed to be complete and reviewed annually. Emergency disaster drills are conducted quarterly, with the last drill documented on 04/01/2025. Smoke and carbon monoxide detectors were tested at 1:00PM and were operational.

MEDICATIONS: Medication review began at 2:42PM. Two (2) residents’ medications were reviewed. Medications are properly documented, and no errors were observed during the medication review.

Two (2) staff and two (2) residents were interviewed during today’s visit. No complaints noted.

No deficiencies cited at this time. Exit interview conducted. A copy of the report was reviewed with the House Manager and provided.

NAME OF LICENSING PROGRAM MANAGER: Kristin Heffernan
NAME OF LICENSING PROGRAM ANALYST: Quoc Huynh
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 06/10/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/10/2025

LIC809 (FAS) - (06/04)

Page: 4 of 4