195850438-5-26-2026-29-AS-CYEE-DUG66B-20260526203136

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 195850438
Report Date: 05/26/2026
Date Signed: 05/26/2026 08:37:58 PM

Document Has Been Signed on 05/26/2026 08:37 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:	SNA ASSISTED LIVING		FACILITY NUMBER:	195850438
ADMINISTRATOR/ DIRECTOR:	ASATRYAN, MARINE		FACILITY TYPE:	740
ADDRESS:	6862 KATHERINE AVENUE		TELEPHONE:	(818) 266-8090
CITY:	VAN NUYS	STATE: CA	ZIP CODE:	91405
CAPACITY: 6		CENSUS: 5	DATE:	05/26/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	10:19 AM
MET WITH:	Mary Mkrtchyan, Staff		TIME VISIT/ INSPECTION COMPLETED:	08:40 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) Christine Yee conducted an unannounced required Annual Inspection and used the CARE Inspection Tool to conduct today's visit. LPA Yee was let into the home by Nvard Manukyan, Staff. Staff contacted Mary Mkrtchyan, staff and she arrived at 11:16am to conduct the visit. The reason for today's visit was provided.

The facility is a single storey family home consisting of a living room, dining room, kitchen, 4 resident bedrooms, an office/staff room, 3 full bathrooms, laundry room and a attached garage. The facility is fire cleared for 5 non-ambulatory residents and 1 bedridden resident. Bedroom #4 is approved for a bedridden resident. Garage is to be used as a garage only.

On today's visit, the following domains of the CARE Inspection Tool were reviewed:

Operational Requirements
Resident Records-Incident Reports
Personnel Records/Staff Training

Also reviewed during the visit were 5 resident and 5 staff files. A tour of the facility, inside and outside was also conducted. The following were observed:

facility records were incomplete and the required documents were not maintained in the resident and staff files.
Three staff - Mary Mkrtchyan, Designated Administrator, Arev Misakyan and Nvard Manukyan, Caregivers, were not associated to the facility.

Continued on LIC809-C

NAME OF LICENSING PROGRAM MANAGER: Kristin Heffernan
NAME OF LICENSING PROGRAM ANALYST: Christine Yee
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/26/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2026

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 11

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 11

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: SNA ASSISTED LIVING	FACILITY NUMBER: 195850438
	VISIT DATE: 05/26/2026

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

Page 2
.

The water in the private bathroom and the common bathroom were tested and did not get hot

Deficiencies cited under California Code of Regulations, Title 22, Division 6, Chapter 8. Civil Penalties of $1500 were assessed. Any deficiencies not addressed on today's visit, will be addressed on a return visit.

Exit interview was conducted, APPEALS RIGHTS were discussed and a copy was provided.

NAME OF LICENSING PROGRAM MANAGER: Kristin Heffernan
NAME OF LICENSING PROGRAM ANALYST: Christine Yee
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/26/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2026

LIC809 (FAS) - (06/04)

Page: 3 of 11

Document Has Been Signed on 05/26/2026 08:37 PM - It Cannot Be Edited

Created By: Christine Yee On 05/26/2026 at 06:45 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: SNA ASSISTED LIVING	FACILITY NUMBER: 195850438
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/26/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87411(f)

Personnel Requirements - General

(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health.Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties. 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 Armenak Saakyan, Licensee/Caregiver did not maintain evidence of a health screening in their file which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 06/02/2026
	Plan of Correction
1 2 3 4	The Licensee will review and ensure that all staff files to contain a health screening with the results of a TB test maintained in their files. Provide evidence that Armenak Saakyan has obtained a health screen and placed in his file by 6/2/26.

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:

	Christine Yee
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/26/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2026

LIC809 (FAS) - (06/04)

Page: 4 of 11

Document Has Been Signed on 05/26/2026 08:37 PM - It Cannot Be Edited

Created By: Christine Yee On 05/26/2026 at 06:45 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: SNA ASSISTED LIVING	FACILITY NUMBER: 195850438
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/26/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Request Denied

Type A

Section Cited

CCR

87355(e)(3)

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: (3) Request a transfer of a criminal record clearance as specified in Section 87355(c) or 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 it was noted that 3 out of 5 facility staff - Mary Mkrtchyan, Nvard Manukyan and Arev Misakyan have not requested a criminal record clearance transfer prior to being present at the facility, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 05/27/2026
	Plan of Correction
1 2 3 4	The Licensee will ensure that all staff, volunteers and any persons who are required to have a criminal record clearance are also associated to the facility prior to being present at the facility. The Licensee will go on Guardian and associate Mary Mkrtchyan, Nvard Manukyan and Arev Misakyan or submit a completed LIC9182 with a copy of a legible driver license to the Department to associate the 3 staff by 5/27/26.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 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.

	Kristin Heffernan
NAME OF LICENSING PROGRAM MANAGER:

	Christine Yee
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/26/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2026

LIC809 (FAS) - (06/04)

Page: 5 of 11

Document Has Been Signed on 05/26/2026 08:37 PM - It Cannot Be Edited

Created By: Christine Yee On 05/26/2026 at 06:45 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: SNA ASSISTED LIVING	FACILITY NUMBER: 195850438
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/26/2026

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 the resident records have incomplete Identification and Emergency Information, missing Consent for Emergency Medical Treatment, no updated Admission Agreements for Resident #2, no doctors orders for use of bed rails which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/02/2026
	Plan of Correction
1 2 3 4	The Licensee, will review all resident records to ensure that all the required documents are in all residents files. Provide evidence that the files have been reviewed and the required documents have been obtained and are in the residents' files by 6/2/26.

Type B

Section Cited

CCR

87463(b)(1)(F)

Reappraisals

(b) The reappraisal shall document significant changes in the resident's physical, mental, cognitive, behavioral, or functional condition, including those required to be documented as specified in Section 87466, Observation of the Resident. (1) Significant changes in condition, as defined in Section 87101, Definitions, include, but are not limited, to: (F) Whether the resident’s and other residents’ safety would be at risk if the resident is allowed to have access to any of the items specified in Section 87307, Personal Accommodations and Services and in Section 87309, Storage Space and Access. 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 reappraisals observed in residents's files were completed but no meetings have been scheduled with the family's or the residentts to discuss the reappraisals or any changes in condition which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/02/2026
	Plan of Correction
1 2 3 4	Licensee will ensure that an annual reappraisal is conducted every 12 months or as needed to document any changes in condition. Licensee shall schedule meetings with families and resident to complete the reappraisals by 6/2/26

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:

	Christine Yee
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/26/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2026

LIC809 (FAS) - (06/04)

Page: 6 of 11

Document Has Been Signed on 05/26/2026 08:37 PM - It Cannot Be Edited

Created By: Christine Yee On 05/26/2026 at 06:45 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: SNA ASSISTED LIVING	FACILITY NUMBER: 195850438
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/26/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87507(c)

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
1 2 3 4	Based on record review, the licensee did not comply with the section cited above as it was observed that Resident #2 and Resident #5 do not have a completed Admission Agreement on file which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/02/2026
	Plan of Correction
1 2 3 4	Licensee will ensure that an Admission Agreement is completed and signed no later than 7 days following admission. Resident #2 (Admitted on5/1/25) and Resident #5 (admitted on 12/1/25) do not have completed Admission Agreements on file. Licensee will obtain completed Admission Agreements and maintain in the residents files by 6/2/26

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 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.

	Kristin Heffernan
NAME OF LICENSING PROGRAM MANAGER:

	Christine Yee
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/26/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2026

LIC809 (FAS) - (06/04)

Page: 7 of 11

Document Has Been Signed on 05/26/2026 08:37 PM - It Cannot Be Edited

Created By: Christine Yee On 05/26/2026 at 07:23 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: SNA ASSISTED LIVING	FACILITY NUMBER: 195850438
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/26/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87411(c)(1)

1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross. 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 Nvard Manukyan, Caregiver, has an expired first aid card and does not have evidence of current training, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/02/2026
	Plan of Correction
1 2 3 4	The Licensee will ensure that all staff have current first aid training from persons qualified by such agencies as the American Red Cross prior to working alone with residents at the facility. Provide evidence that Nvard Manukyan has obtained current training by 6/2/26

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 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.

	Kristin Heffernan
NAME OF LICENSING PROGRAM MANAGER:

	Christine Yee
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/26/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2026

LIC809 (FAS) - (06/04)

Page: 11 of 11