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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195850350
Report Date: 05/12/2026
Date Signed: 05/12/2026 06:14:33 PM

Document Has Been Signed on 05/12/2026 06:14 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:
05/12/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:45 AM
MET WITH:Tigran GevorgyanTIME VISIT/
INSPECTION COMPLETED:
06:20 PM
NARRATIVE
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Licensing Program Analyst (LPA) Trevor Byrne arrived at the facility unannounced to conduct the required annual visit at 09:45 AM. LPA met with facility staff and contacted the facility Administrator Tigran Gevorgyan. The Administrator arrived to the facility at approximately 10:45 AM and was joined by Naira Spry (I1). Entrance interview was conducted and the reason for the visit was explained.

Beginning at 09:48 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:

KITCHEN: The LPA observed the kitchen area to be clean. Kitchen appliances appeared to be in operable condition. The facility had a sufficient supply of two (2) days perishable and seven (7) days non-perishable food. LPA observed a secured drawer which contained knives and other sharp objects. LPA observed an unsecured pair of scissors in a kitchen drawer. LPA notified S1, who secured the items. LPA observed a locked under-sink storage which contained cleaning chemicals. LPA observed a locked medication cabinet. LPA observed a box of unsecured supplements. LPA informed S1 who stated that the supplements belonged to the facility staff members. S1 secured the supplements at the time of the visit. LPA did not observe a fire extinguisher in the kitchen area. LPA asked S1 where the facility’s fire extinguisher was located. S1 informed LPA that the facility was in the process of moving to a new location and the fire extinguisher was recently removed and transferred to the new location. LPA informed S1 and later the Administrator that the facility is required to maintain a fully charged and serviced fire extinguisher on the facility grounds at all times as a requirement of the facility’s fire clearance. CONTINUED ON LIC 809C.

NAME OF LICENSING PROGRAM MANAGER: Kasandra Lopez
NAME OF LICENSING PROGRAM ANALYST: Trevor Byrne
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/12/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/12/2026
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 17
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: 05/12/2026
NARRATIVE
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KITCHEN CONT.: LPA informed the Administrator that the violation of the facility’s fire clearance is a zero-tolerance violation and an immediate civil penalty in the amount of $500 will be assessed on today’s date (05/12/2026). The Administrator expressed understanding and obtained a fire extinguisher for the facility at the time of the visit.

COMMON AREAS: This included 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 contained a television, activities for resident use, and a fireplace that was appropriately screened and contained no tools. Additionally, the living room/dining area contained a table and adequate seating for resident use. The hallway was observed to be free from obstructions and contained storage for the facility’s linens. The office area was observed to contain a locked storage cabinet that contained facility, staff, and resident files. Additionally, the office area contained an unlocked dresser that contained the facility’s first aid kit and caregiver’s personal items which included hygiene items. The facility’s combination fire and carbon monoxide alarms were tested at 10:20 AM and were functional at the time of the visit. During the physical plant tour and file review LPA observed that the facility was experiencing a cockroach infestation evidenced by cockroaches inside facility files and near the kitchen table. LPA notified the Administrator who stated that they were aware of the problem. The Administrator stated that they had notified the landlord of the cockroach and bedbug infestation that was ongoing at the facility but the landlord of the property failed to assist in mitigating the problem.

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 contained a direct exit to the outdoors of the facility. LPA observed exits in the resident bedrooms and throughout the facility to contain non-functioning auditory alarms. LPA observed three (3) resident beds to contain full bed rails. During file review LPA was informed by the Administrator that no residents of the facility were on hospice. LPA informed the Administrator that bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails. The Administrator expressed understanding and agreed to remove the rails from the resident’s beds. Additionally, LPA observed unsecured hygiene items throughout the resident bedrooms.

CONTINUED ON LIC 809C.

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

DATE: 05/12/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2026
LIC809 (FAS) - (06/04)
Page: 3 of 17
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: 05/12/2026
NARRATIVE
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BATHROOMS: There are two (2) bathrooms at the facility. One (1) designated as a staff (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 storage cabinet that contained soaps and other hygiene items, LPA observed this cabinet to be unlocked at the time of the inspection. The water temperature was initially measured to be between 138.2 and 138.9 degrees Fahrenheit, which is outside of the range required by regulation. The Administrator adjusted the temperature on the hot water heater during the visit. LPA tested the water temperature again and measured the temperature to be 117.5 degrees Fahrenheit which is in compliance with regulation. During the physical plant tour LPA was informed by S1 that the bathroom attached to bedroom #3 was utilized as a staff only bathroom. LPA informed S1 and the Administrator that no bedroom of a resident shall be used as a passageway to another room, bath or toilet. The Administrator expressed understanding and agreed to utilize this bathroom as a resident bathroom.

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 had adequate shaded seating outdoors for resident use. The backyard of the facility contained a laundry room which contained the facility’s washer and dryer along with laundry chemicals and pesticides. LPA observed this room to be unlocked at the time of the visit. Additionally, LPA observed a locked storage shed and a separate dwelling with its own address that is not associated to the facility. During the physical plant tour LPA was informed by S1 and later the Administrator that the back house (7827 Simpson Ave, North Hollywood, CA 91605) was being operated as an “Independent Living Facility”. LPA was informed by S1 that five (5) individuals were residing in the back home. LPA observed that the individuals residing in the back home had access to the clients in care at the licensed facility. During file review LPA observed one (1) individual from the back home enter the facility and ask S1 for a meal. LPA informed the Administrator that since the tenants of the back home had access to the clients in care, individuals that resident in the back home require fingerprint clearance and association to the facility. The Administrator stated that they were aware of this requirement as one (1) of five (5) individuals had fingerprint clearance and association to the facility at the time of the inspection. The Administrator stated that all individuals in the back house had resided at the location for more than one (1) week.

CONTINUED ON LIC 809C.

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

DATE: 05/12/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2026
LIC809 (FAS) - (06/04)
Page: 4 of 17
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: 05/12/2026
NARRATIVE
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RECORD REVIEW: Record review began at 10:40 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. Two (2) staff files were reviewed. One (1) staff file was observed to be missing up to date trainings. LPA requested to review Staff #2’s (S2) file but was informed by S1 that S2 was recently hired and did not have a completed staff file. LPA informed the Administrator that personnel records must be maintained on the licensee, Administrator and each employee. The Administrator expressed understanding and agreed to submit a completed staff file for S2 to Community Care Licensing Division (CCLD). During record review LPA observed that I1, S2, and four (4) individuals residing in the back house were not fingerprint cleared/associated to the facility. LPA informed the Administrator that prior to employment or initial presence in the facility individuals subject to a criminal record review shall obtain a California clearance or a criminal record exemption as required by law or Department regulations. LPA informed the Administrator that a civil penalty in the amount of $3000 is being assessed on today’s date for six (6) individuals without appropriate criminal record clearance. (6 Individuals x $100 /day x 5 days [1st offence, 5 day maximum] = $3,000 total penalty). The Administrator expressed understanding and agreed to obtain criminal record clearance and associate all individuals with access to the clients to the facility. Five (5) resident files were reviewed. Four (4) resident appraisal needs and services plan (ANS) were not updated annually. LPA informed the Administrator that, appraisals shall be updated in writing as frequently as necessary or once every 12 months, whichever occurs first. The Administrator expressed understanding and agreed to submit updated ANS for the identified residents to CCLD. One (1) resident file was observed to be missing all documentation except their Centrally Stored Medication and Destruction Record Sheets (CSMDRs). LPA informed the Administrator who stated that the resident was looking to relocate from the facility and paperwork had not been completed. LPA informed the Administrator that the facility shall ensure that a separate, complete, and current record is maintained for each resident in the facility. The Administrator expressed understanding and agreed to submit a complete resident file for the identified resident to CCLD.

MEDICATION REVIEW: Medication review began at approximately 12:30 PM. Medications for three (3) of five (5) residents were observed. All observed CSMDRs were observed to contain incorrect and out of date information including: dates filled, prescription numbers, names of medications, and dosage of medications.

CONTINUED ON LIC 809C.

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

DATE: 05/12/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2026
LIC809 (FAS) - (06/04)
Page: 5 of 17
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: 05/12/2026
NARRATIVE
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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 they pertain to infection control are adequate. Emergency disaster drills are to be conducted quarterly; the facility’s last emergency disaster drill was conducted on 04/02/2025 which is outside of the range required by regulation. The facility’s emergency disaster plan contained outdated information pertaining to the emergency equipment the facility had on hand. Both the infection control plan and the emergency disaster plan were not reviewed/updated annually by the facility’s Administrator.

INTERVIEWS: LPA interviewed two (2) residents. The residents interviewed stated that the staff treat them well and are attentive to their needs. The 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.

During today’s visit LPA was informed that the facility would be transferring their location to a new home in Northridge. LPA informed the Administrator that they were not notified of the change of location. The Administrator stated that they had been in contact with the Centralized Application Bureau throughout the process. LPA was notified that the landlord had refused to renew the lease on the property and the facility’s control of the property lapsed on 05/01/2026. The Administrator informed LPA that the landlord had approved a two (2) week extension and the facility would remain in control of the property until 05/16/2026. LPA informed the Administrator that this should have been reported to CCLD along with other incidents which threatened the health, safety, and welfare of the residents in care. The Administrator stated that CCLD was notified. LPA reviewed the facility’s file and observed the last submitted incident report was received in February 2025. The Administrator did not provide LPA with proof of incident report submissions at the time of the visit. LPA notified the Administrator that any incident which threatens the welfare, safety or health of any resident shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence. During today’s visit LPA obtained a copy of the facility’s LIC 500, resident roster, emergency disaster plan, and current liability insurance.

Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited and civil penalties assessed. (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: 05/12/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2026
LIC809 (FAS) - (06/04)
Page: 6 of 17
Document Has Been Signed on 05/12/2026 06:14 PM - It Cannot Be Edited


Created By: Trevor Byrne On 05/12/2026 at 03:52 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: 05/12/2026

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
1
2
3
4
Based on observation and interview, the licensee did not comply with the section cited above as the facility did not have a fire extinguisher located on the premises at the time of the inspection which posed an immediate safety risk to persons in care.
POC Due Date: 05/12/2026
Plan of Correction
1
2
3
4
Administrator obtained a fire extinguisher at the time of the visit. POC cleared.
Type A
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(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
1
2
3
4
Based on observation, the licensee did not comply with the section cited above as the facility's water temperature was measured to be above 120 degrees F which posed an immediate health risk to persons in care.
POC Due Date: 05/12/2026
Plan of Correction
1
2
3
4
Administrator adjusted the water temperature to an appropriate level 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: 05/12/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/12/2026


LIC809 (FAS) - (06/04)
Page: 7 of 17
Document Has Been Signed on 05/12/2026 06:14 PM - It Cannot Be Edited


Created By: Trevor Byrne On 05/12/2026 at 03:52 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: 05/12/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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
1
2
3
4
Based on observation, the licensee did not comply with the section cited above as scissors were left unsecured in a kitchen drawer which posed an immediate safety risk to persons in care.
POC Due Date: 05/12/2026
Plan of Correction
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2
3
4
Staff secured the items at the time of the visit. POC cleared.
Type A
Section Cited
CCR
87309(c)
Storage Space and Access
(c) Except as specified in subsection (d), the licensee shall implement reasonable interventions in order to ensure that nutritional supplements, vitamins, alcohol, cigarettes and other potentially toxic substances, such as certain plants, gardening supplies, and auto supplies, are stored so as not to pose a hazard to residents.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above as a box of supplements were left unsecured which posed an immediate health risk to persons in care.
POC Due Date: 05/12/2026
Plan of Correction
1
2
3
4
Staff 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: 05/12/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/12/2026


LIC809 (FAS) - (06/04)
Page: 8 of 17
Document Has Been Signed on 05/12/2026 06:14 PM - It Cannot Be Edited


Created By: Trevor Byrne On 05/12/2026 at 03:52 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: 05/12/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87355(e)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview, and record review, the licensee did not comply with the section cited above as six individuals with access to the residents and resided/worked on the property containing the facility were not finger print cleared/associated to the facility which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/15/2026
Plan of Correction
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2
3
4
Administrator agreed to obtain fingerprint clearance and association to the facility for all identified individuals and to submit proof of association/clearance to CCLD no later than POC due date.
Section Cited
Deficient Practice Statement
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2
3
4
POC Due Date:
Plan of Correction
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2
3
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: 05/12/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/12/2026


LIC809 (FAS) - (06/04)
Page: 9 of 17
Document Has Been Signed on 05/12/2026 06:14 PM - It Cannot Be Edited


Created By: Trevor Byrne On 05/12/2026 at 03:52 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: 05/12/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87211(a)(1)
Reporting Requirements
(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on interview and record review, the licensee did not comply with the section cited above as incidents of hospitalization of residents, infestation, etc. were not reported to CCLD within the required timeframe which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/26/2026
Plan of Correction
1
2
3
4
Administrator agreed to submit their plan on how they will ensure appropriate reporting of incidents which affect residents to CCLD within the required timeframe. Administrator agreed to submit their plan to CCLD no later than POC due date.
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
1
2
3
4
Based on observation, the licensee did not comply with the section cited above as the facility is currently experiencing an infestation of cockroaches and bedbugs which poses/posed a potential health risk to persons in care.
POC Due Date: 05/26/2026
Plan of Correction
1
2
3
4
Administrator agreed to undertake efforts to control the infestation and to mitigate the impacts to residents. Administrator agreed to submit proof of their efforts to CCLD no later than POC 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.
Kasandra Lopez
NAME OF LICENSING PROGRAM MANAGER:
Trevor Byrne
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/12/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/12/2026


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Document Has Been Signed on 05/12/2026 06:14 PM - It Cannot Be Edited


Created By: Trevor Byrne On 05/12/2026 at 03:52 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: 05/12/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.625(b)(1)
Other Provisions
(1) The department shall adopt regulations to require staff members of residential care facilities for the elderly who assist residents with personal activities of daily living to receive appropriate training. This training shall consist of 40 hours of training. A staff member shall complete 20 hours, including six hours specific to dementia care, as required by subdivision (a) of Section 1569.626 and four hours specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696, before working independently with residents. The remaining 20 hours shall include six hours specific to dementia care and shall be completed within the first four weeks of employment. The training coursework may utilize various methods of instruction, including, but not limited to, lectures, instructional videos, and interactive online courses. The additional 16 hours shall be hands-on training.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above as two facility staff did not have the required annual/initial trainings logged in their files which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/26/2026
Plan of Correction
1
2
3
4
Administrator agreed to complete annual/initial trainings with the identified staff members and to submit proof of the completed trainings to CCLD no later than POC 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.
Kasandra Lopez
NAME OF LICENSING PROGRAM MANAGER:
Trevor Byrne
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/12/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/12/2026


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Document Has Been Signed on 05/12/2026 06:14 PM - It Cannot Be Edited


Created By: Trevor Byrne On 05/12/2026 at 03:52 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: 05/12/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87506(a)
Resident Records
(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above as one resident file was missing all required information except a CSMDR which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/26/2026
Plan of Correction
1
2
3
4
Administrator agreed to submit a completed resident file for the identified resident to CCLD no later than POC due date.
Type B
Section Cited
CCR
87463(a)
Reappraisals
(a) The pre-admission appraisal, as specified in Section 87457, Pre-Admission Appraisal, shall be updated, in writing as frequently as necessary or once every 12 months, whichever occurs first, to note significant changes in condition, as defined in Section 87101, Definitions, and to keep the appraisal accurate. For the purposes of this section, the updated pre-admission appraisal shall be referred to as the reappraisal.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above as 4 residents had Appraisals that were last updated more than 12 months prior which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/26/2026
Plan of Correction
1
2
3
4
Administrator agreed to complete updated appraisals for the identified residents and to send proof of the completed appraisals to CCLD no later than POC 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.
Kasandra Lopez
NAME OF LICENSING PROGRAM MANAGER:
Trevor Byrne
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/12/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/12/2026


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Document Has Been Signed on 05/12/2026 06:14 PM - It Cannot Be Edited


Created By: Trevor Byrne On 05/12/2026 at 03:52 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: 05/12/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(a)
Other Provisions
(a)In addition to any other requirement of this chapter, a residential care facility for the elderly shall have an emergency and disaster plan that shall include, but not be limited to, all of the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above as the facility's emergency disaster plan contained inaccurate/out of date information pertaining to the emergency supplies on hand which posed a potential safety risk to persons in care.
POC Due Date: 05/12/2026
Plan of Correction
1
2
3
4
Administrator updated the disaster plan at the time of the visit. POC cleared.
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above as the facility did not conduct an emergency disaster drill quarterly which pose a potential safety risk to persons in care.
POC Due Date: 05/26/2026
Plan of Correction
1
2
3
4
Administrator agreed to complete an emergency disaster drill and to send proof of the completed drill to CCLD no later than POC 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.
Kasandra Lopez
NAME OF LICENSING PROGRAM MANAGER:
Trevor Byrne
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/12/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/12/2026


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Document Has Been Signed on 05/12/2026 06:14 PM - It Cannot Be Edited


Created By: Trevor Byrne On 05/12/2026 at 03:52 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: 05/12/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(d)
Other Provisions
(d) A facility shall review the plan annually and make updates as necessary, including changes in floor plans and the population served. The licensee or administrator shall sign and date documentation to indicate that the plan has been reviewed and updated as necessary.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above as the facility's emergency disaster plan was not reviewed at least annually which poses a potential safety risk to persons in care.
POC Due Date: 05/12/2026
Plan of Correction
1
2
3
4
Administrator updated and reviewed the plan at the time of the visit. POC cleared.
Type B
Section Cited
CCR
87608(a)(5)(B)
Postural Supports
(B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview, and record review, the licensee did not comply with the section cited above as three residents who were not on hospice had full bed rails installed which poses a potential personal rights risk to persons in care.
POC Due Date: 05/26/2026
Plan of Correction
1
2
3
4
Administrator agreed to remove the bed rails and to send proof of the removed rails to CCLD no later than POC 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.
Kasandra Lopez
NAME OF LICENSING PROGRAM MANAGER:
Trevor Byrne
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/12/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/12/2026


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Document Has Been Signed on 05/12/2026 06:14 PM - It Cannot Be Edited


Created By: Trevor Byrne On 05/12/2026 at 04:19 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: 05/12/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87307(a)(2)(C)

87307 Personal Accommodations and Services
(a) Living accommodations and grounds shall be related to the facility's function. The facility shall be large enough to provide comfortable living accommodations and privacy for the residents, staff, and others who may reside in the facility. The following provisions shall apply:
(2) Resident bedrooms shall be provided which meet, at a minimum, the following requirements:
(C) No bedroom of a resident shall be used as a passageway to another room, bath or toilet.

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 a bathroom that is attached to a resident room was utilized as a staff only bathroom which poses a potential personal rights risk to persons in care.
POC Due Date: 05/26/2026
Plan of Correction
1
2
3
4
Administrator agreed to submit a statement of understanding confirming that they will utilize the attached bathroom as a resident bathroom only and that no resident room will be used as a passageway to another room, bath, or toilet. Administrator agreed to submit the statement to CCLD no later than POC due date.
Type B
Section Cited
CCR
87211(a)
87211 Reporting Requirements
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on interview and record review, the licensee did not comply with the section cited above as one staff member did not have a completed file located at the facility which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/26/2026
Plan of Correction
1
2
3
4
Administrator agreed to submit a completed staff file for the identified staff membert to CCLD no later than POC 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.
Kasandra Lopez
NAME OF LICENSING PROGRAM MANAGER:
Trevor Byrne
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/12/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/12/2026


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Document Has Been Signed on 05/12/2026 06:14 PM - It Cannot Be Edited


Created By: Trevor Byrne On 05/12/2026 at 04:24 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: 05/12/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87705(d)
87705 Care of Persons with Dementia
(d) The licensee shall ensure that the facility has an auditory device or other staff alert feature to monitor exits on exterior doors and perimeter fence gates accessible to those residents who may be at risk for elopement, as defined in Section 87101, Definitions.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above as all facility exits contained non-functioning auditory alarms which poses a potential safety risk to persons in care.
POC Due Date: 05/26/2026
Plan of Correction
1
2
3
4
Administrator agreed to submit proof of functioning auditory alarms on all facility exits to CCLD no later than POC due date.
Type B
Section Cited
CCR
87465(h)(6)
87465 Incidental Medical and Dental Care
(h) The following requirements shall apply to medications which are centrally stored:
(6) The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least one year and includes:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above as three resident CSMDRs contained inaccurate information including date filled, prescription numbers, dates started, etc. which poses a potential health risk to persons in care.
POC Due Date: 05/26/2026
Plan of Correction
1
2
3
4
Administrator agreed to submit proof of accurate CSMDRs for the identified residents to CCLD no later than POC 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.
Kasandra Lopez
NAME OF LICENSING PROGRAM MANAGER:
Trevor Byrne
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/12/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/12/2026


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