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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195850430
Report Date: 02/25/2025
Date Signed: 02/25/2025 07:00:08 PM

Document Has Been Signed on 02/25/2025 07:00 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:ANGELS HANDS SENIOR LIVINGFACILITY NUMBER:
195850430
ADMINISTRATOR/
DIRECTOR:		GHUKASYAN, MARINEFACILITY TYPE:
740
ADDRESS:14819 VALERIO STREETTELEPHONE:
(818) 679-4442
CITY:VAN NUYSSTATE: CAZIP CODE:
91405
CAPACITY: 6CENSUS: 3DATE:
02/25/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
06:23 PM
MET WITH:Marine Ghukasyan, AdministratorTIME VISIT/
INSPECTION COMPLETED:
07:10 PM
NARRATIVE
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Licensing Program Analyst(LPA) Christine Yee conducted an unannounced case management visit due to a deficiency noted during a visit to the facility today. The reason for the visit was explained.

Per review of facility files, criminal record clearance documents were observed in the below staffs' files. However, neither staff noted below are associated to the facility.
  • Gervog Gevshenyan, Staff is not associated to the facility
  • Armine Safaryan, Staff is not associated to the facility


Deficiencies cited under California Code of Regulations, Title 22, Division 6, Chapter 8. CIVIL PENALTIES were assessed.

Exit interview was conducted, APPEALS RIGHTS were discussed and a copy was given
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Christine Yee
LICENSING EVALUATOR SIGNATURE: DATE: 02/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/25/2025
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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Document Has Been Signed on 02/25/2025 07:00 PM - It Cannot Be Edited


Created By: Christine Yee On 02/25/2025 at 06:36 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: ANGELS HANDS SENIOR LIVING
FACILITY NUMBER: 195850430

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/25/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/26/2025
Section Cited
CCR
87355(e)(2)

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Criminal Record Clearance: 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: Request a transfer of a criminal record clearance as specified in Section 87355(c) or
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Licensee will ensure that all staff, volunteers or individuals who require to be associated to the facility are associated prior to being present at the facility. LIcensee will associate the 2 staff to the facility via Guardian or submit a completed LIC9182 with a legible copy of their driver license
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This requirement was not met as evidenced by:
Staff Armine Safaryan and Gervog Gevshenyan are not associated to the home.
$1000 CIVIL PENALTIES WERE ASSESSED.
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to the Regional office by 2/26/25.

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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Kristin Heffernan
LICENSING EVALUATOR NAME:Christine Yee
LICENSING EVALUATOR SIGNATURE:
DATE: 02/25/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/25/2025


LIC809 (FAS) - (06/04)
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