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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195850350
Report Date: 05/02/2025
Date Signed: 05/02/2025 04:29:14 PM

Document Has Been Signed on 05/02/2025 04:29 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:LA SENIOR HOMEFACILITY NUMBER:
195850350
ADMINISTRATOR/
DIRECTOR:		SPRY, NAIRAFACILITY TYPE:
740
ADDRESS:7825 SIMPSON AVENUETELEPHONE:
(818) 299-7501
CITY:NORTH HOLLYWOODSTATE: CAZIP CODE:
91605
CAPACITY: 5CENSUS: 5DATE:
05/02/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:27 AM
MET WITH:Tigran GevorgyanTIME VISIT/
INSPECTION COMPLETED:
04:30 PM
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Licensing Program Analyst (LPA) Trevor Byrne arrived at the facility unannounced to conduct a required annual visit at 09:27 AM. LPA met with facility staff and contacted the facility Administrator Naira Spry. The Administrator stated that they are unable to come to the facility during today’s inspection, but the Owner/Licensee Representative Tigran Gevorgyan (LIC) would be arriving to conduct the visit. LIC arrived to the facility at approximately 10:00 AM. Entrance interview conducted and the reason for the visit was explained.

Beginning at 09:30 AM the LPA, along with facility staff #1 (S1) toured the physical plant areas inside and outside to ensure there are no health and safety hazards and that facility is in compliance with Title 22 Regulations. The following was observed:

COMMON AREAS: This includes the living room/dining area, hallway, and office area. LPA observed the living room/dining area to be clean and properly furnished at the time of the visit. The living room contains a television, activities for resident use, and a fireplace that is appropriately screened and contains no tools. Additionally, the living room/dining area contained a table and adequate seating for resident use. The hallway was observed to be clean and free from obstructions. The office area was observed to contain a locked storage cabinet that contained facility files. Additionally, the office area contained an unlocked storage dresser that contained the facility’s first aid kit and caregiver’s personal items. LPA observed this dresser to contain unsecured resident medications including prescription inhalers, ointments, and staff supplements. Facility staff secured all medications at the time of the visit. The facility’s combination fire and carbon monoxide alarms were tested at 01:02 PM and were functional at the time of the visit. Continued on 809C.
NAME OF LICENSING PROGRAM MANAGER: Kasandra Lopez
NAME OF LICENSING PROGRAM ANALYST: Trevor Byrne
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/02/2025
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.

LIC809 (FAS) - (09/23)
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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: LA SENIOR HOME
FACILITY NUMBER: 195850350
VISIT DATE: 05/02/2025
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BEDROOMS: There are three (3) bedrooms in the facility; two (2) are dual occupancy resident rooms and one (1) is a single occupancy resident room. LPA and S1 toured all three (3) resident bedrooms. All resident rooms were observed to be furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting. Bedroom #3 contains a direct exit to the outdoors of the facility.

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. LPA observed a secured drawer to contain knives and other sharp objects. LPA observed a fire extinguisher to be purchased on 05/21/2024. The kitchen contained a locked under-sink storage containing cleaning chemicals. LPA observed two unlocked kitchen drawers to contain gardening shears and a large sharp two-pronged fork. Facility staff secured the objects during the inspection.

BATHROOMS: There are two (2) bathrooms at the facility. One (1) designated as a private bathroom, and one (1) is designated as a shared/common resident bathroom. All bathrooms were observed to be clean and were equipped with nonskid surfaces. Grab bars were observed in all resident showers and near all resident toilets, all were properly secured. The shared resident bathroom contained a locked storage cabinet that contained soaps and other hygiene items. The water temperature was initially measured to be between 127.2 and 128.1 degrees Fahrenheit, which is outside of the range required by regulation. LIC adjusted the temperature on the hot water heater during the visit. LPA tested the water temperature again and measured the temperature to be 107.8 degrees Fahrenheit which is in compliance with regulation.

OUTDOOR SPACE: The facility has one (1) emergency exit gate located at the front of the facility; LPA observed clear passageways for emergency exit use. The facility has adequate shaded seating outdoors for resident use. The backyard of the facility contained a locked laundry room. The laundry room contained the facility’s washer and dryer along with laundry chemicals. Additionally, LPA observed a locked storage shed and a separate dwelling with its own address that is not associated to the facility.

Continued on LIC 809C.
NAME OF LICENSING PROGRAM MANAGER: Kasandra Lopez
NAME OF LICENSING PROGRAM ANALYST: Trevor Byrne
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/02/2025
LIC809 (FAS) - (06/04)
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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: LA SENIOR HOME
FACILITY NUMBER: 195850350
VISIT DATE: 05/02/2025
NARRATIVE
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RECORD REVIEW: Record review began at 10:20 AM. Staff and resident records were reviewed for documents including, but not limited to: health screening, TB test, staff training records, fingerprint clearance, resident physician's report, needs and service appraisal, consent forms, and personal rights. Three (3) staff files were reviewed. All staff files contained all required documents and trainings. Five (5) resident files were reviewed. Four (4) resident admission agreements were observed to be incomplete and missing signatures and/or the rates charged for basic services. LPA informed LIC, three (3) residents were self-responsible and completed the admission agreements during the inspection. LIC stated that the remaining admission agreement would be completed no later than 05/16/2025.

MEDICATION REVIEW: Medication review began at 11:50 AM. Medications for five (5) of five (5) residents were observed. Four (4) of five (5) resident’s Centrally Stored Medication and Destruction Record Sheets (CSMDR) were observed to contain incorrect and out of date information including: dates filled, prescription numbers, names of medications, and dosage of medications. LPA reviewed five (5) resident’s Medication Administration Records (MAR). All medications were observed to be logged appropriately and the number of pills remaining in medication bottles was consistent with appropriate administration of the medications. LPA informed LIC of the inaccuracies on the CSMDRs and facility staff updated the four (4) identified resident CSMDRs to accurately reflect their prescribed medications during the visit.

INFECTION CONTROL/EMERGENCY DISASTER PLANNING: During today’s visit, the LPA reviewed the
facility's infection control practices and the facility's emergency disaster plan. The facility’s policies and procedures as it pertains to infection control are adequate. Emergency disaster drills are conducted quarterly; the facility’s last emergency disaster drill was conducted on 04/02/2025. The facility’s emergency disaster plan is up to date and is adequate. Both the infection control plan and the emergency disaster plan are reviewed/updated annually by the facility’s Administrator.

INTERVIEWS: LPA interviewed three (3) residents. Two (2) of the three (3) residents interviewed stated that the staff treat them well and are attentive to their needs. Two (2) of the three (3) residents interviewed had no concerns with the facility. LPA interviewed one (1) staff member. The staff member interviewed was knowledgeable on their roles and responsibilities, the resident’s rights, the forms of abuse, and the appropriate reporting procedures for suspected abuse.

Continued on LIC 809C.

NAME OF LICENSING PROGRAM MANAGER: Kasandra Lopez
NAME OF LICENSING PROGRAM ANALYST: Trevor Byrne
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/02/2025
LIC809 (FAS) - (06/04)
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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: LA SENIOR HOME
FACILITY NUMBER: 195850350
VISIT DATE: 05/02/2025
NARRATIVE
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During today’s visit LPA obtained a copy of the facility’s LIC 500, resident roster, and current liability insurance.

Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D): Exit interview conducted and copy of the report was issued and appeal rights provided.

NAME OF LICENSING PROGRAM MANAGER: Kasandra Lopez
NAME OF LICENSING PROGRAM ANALYST: Trevor Byrne
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/02/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/02/2025 04:29 PM - It Cannot Be Edited


Created By: Trevor Byrne On 05/02/2025 at 03:21 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: LA SENIOR HOME
FACILITY NUMBER: 195850350

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/02/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

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 hot water temperature measured at resident faucets exceeded 120 degrees Fahrenheit which posed an immediate health risk to persons in care.
POC Due Date: 05/02/2025
Plan of Correction
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Licensee adjusted the water temperature to be within the required range during the visit. POC 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 gardening shears and a large sharp two-pronged fork were unsecured in the kitchen drawer which poses an immediate safety risk to persons in care.
POC Due Date: 05/02/2025
Plan of Correction
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Licensee secured the items at the time of the visit. POC cleared.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Kasandra Lopez
NAME OF LICENSING PROGRAM MANAGER:
Trevor Byrne
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/02/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/02/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/02/2025 04:29 PM - It Cannot Be Edited


Created By: Trevor Byrne On 05/02/2025 at 03:21 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: LA SENIOR HOME
FACILITY NUMBER: 195850350

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/02/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored:

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 prescription medications, inhalers, ointments, and staff supplements were not securely stored and four (4) residents centrally stored medication and destruction record sheets contained inaccurate information including dates filled, prescription numbers, names of medications, and dosage of medications which poses an immediate health and safety risk to persons in care.
POC Due Date: 05/02/2025
Plan of Correction
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The prescription medications and supplements were properly secured during the visit and four (4) CSMDRs were updated to accurately reflect current resident medications. POC cleared.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Kasandra Lopez
NAME OF LICENSING PROGRAM MANAGER:
Trevor Byrne
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/02/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/02/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/02/2025 04:29 PM - It Cannot Be Edited


Created By: Trevor Byrne On 05/02/2025 at 03:22 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: LA SENIOR HOME
FACILITY NUMBER: 195850350

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/02/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87507(c)
87507 Admission Agreements
(c) Admission agreements shall be signed and dated, acknowledging the contents of the document, by the resident or the resident’s representative, if any, and the licensee or the licensee’s designated representative no later than seven days following admission. Attachments to the agreement may be utilized as long as they are also signed and dated as prescribed above.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above as four (4) resident admission agreements were not completed and were missing signatures and/or initials which poses a potential personal rights risk to persons in care.
POC Due Date: 05/16/2025
Plan of Correction
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Three admission agreements were completed and signed during the visit. Licensee will submit the remaining admission agreement to CCLD no later than POC due date.
Type B
Section Cited
CCR
87507(g)(3)(A)
87507 Admission Agreements
(g) Admission agreements shall specify the following:
(3) Payment provisions, including the following:
(A) Rate for all basic services which the facility is required to provide in order to obtain and maintain a license. Basic services rate(s), including:
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above as two (2) resident admission agreements were not completed and were missing rates for basic services which poses a potential personal rights risk to persons in care.
POC Due Date: 05/02/2025
Plan of Correction
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Admission agreements were updated with accurate rates for basic services and were reviewed by self-responsible residents during the visit. POC cleared.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Kasandra Lopez
NAME OF LICENSING PROGRAM MANAGER:
Trevor Byrne
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/02/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/02/2025


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