195850501-7-9-2026-29-AS-CYEE-DVU62K-20260709202541

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 195850501
Report Date: 07/09/2026
Date Signed: 07/09/2026 08:26:00 PM

Document Has Been Signed on 07/09/2026 08:26 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	BELLAIRE SENIOR CARE		FACILITY NUMBER:	195850501
ADMINISTRATOR/ DIRECTOR:	GEVORGYAN, EVA		FACILITY TYPE:	740
ADDRESS:	6523 BELLAIRE AVENUE		TELEPHONE:	(818) 987-1115
CITY:	NORTH HOLLYWOOD	STATE: CA	ZIP CODE:	91606
CAPACITY: 6		CENSUS: 4	DATE:	07/09/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	10:50 AM
MET WITH:	Erna Gevorgyan, Administrator		TIME VISIT/ INSPECTION COMPLETED:	08:25 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 on today's visit. LPA Yee was let into the home by Ramila Sultanova, Staff. Erna Gevorgyan, Administrator was contacted by staff and she arrived at 11:05 am to conduct the visit. Also present during the visit was David Abramyan, Staff. The reason for today's visit was provided. The facility is a single storey family home consisting of a living room, dining room, kitchen, 3 bedrooms, 2 full bathrooms and a car port. The facility is fire cleared for 5 non-ambulatory and 1 bedridden resident. Bedroom #1(back) is designated for bedridden use for the one resident. Located in the back of the facility is an ADU with it's own address of 6521 Bellaire Avenue that is rented out. On today's visit, all 12 domains of the CARE Inspection Tool was reviewed, 4 Resident files and 5 staff files were reviewed and a tour of the physical plant was conducted. The following were observed on today's visit: the living room and dining room are furnished with the appropriate furniture and sitting for 6 residents the kitchen is equipped with a refrigerator, dishwasher, toaster oven, microwave and coffee maker. sufficient plates, cups and bowls were observed. knives were observed in a locked kitchen drawer. cleaning solutions, dish detergent and laundry detergent are locked in a cabinet under the kitchen sink

NAME OF LICENSING PROGRAM MANAGER: Kristin Heffernan
NAME OF LICENSING PROGRAM ANALYST: Christine Yee
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 07/09/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2026

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: BELLAIRE SENIOR CARE	FACILITY NUMBER: 195850501
	VISIT DATE: 07/09/2026

NARRATIVE

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and in a locked cabinet in the common bathroom.
Medications are locked in a cabinet in the kitchen.
The facility has current general liability insurance that meets Title 22 requirements
First Aid kit containing a pair of scissors, tweezer and thermometer and first aid manual was observed.
All three bedrooms were observed with 2 hospital beds each, 2 chairs, 2 night stands, 2 lamps and a built in closet. Half bed rails were observed on the right bed in bedroom #2 and full bed rails were observed on the left bed in bedroom #3. Resident in bedroom #3 is receiving hospice services.
bed linens were observed
Located inside bedroom #1 is a private bathroom equipped with a walk in shower, a shower chair, grab bars and slip resistant mat, a toilet and a single sink. Hygiene products are stored in a locked dresser drawer placed in the bathroom. Water temperature was tested and read 110.0 degrees Fahrenheit.
The common bathroom is equipped with a walk in shower, toilet and a single sink. A slip resistant mat and grab bars in the shower and the toilet were observed. The water temperature was tested and read 110.0 degrees Fahrenheit.
2 fire extinguishers were observed in the kitchen.
the air conditioner was operational
the hardwired combination smoke/carbon monoxide detector located in the resident hallway and the 3 smoke detectors located inside the resident bedrooms and in the dining room were tested and were operational.
The auditory device on the 3 outside exiting doors - bedroom #1, kitchen and front door -were tested and were operational
The backyard was observed with a table and six chairs under a covered patio. Also located under the covered patio was a washer and dryer. Overall the inside and outside of the facility were observed to be clean
The trash cans were observed out on the curb for trash pick up.

Deficiencies were cited under California Code of Regulations, Title 22, Division 6, Chapter 8

Exit interview was conducted, Appeals Rights were discussed and a copy was given.

NAME OF LICENSING PROGRAM MANAGER: Kristin Heffernan
NAME OF LICENSING PROGRAM ANALYST: Christine Yee
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 07/09/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2026

LIC809 (FAS) - (06/04)

Page: 3 of 5

Document Has Been Signed on 07/09/2026 08:26 PM - It Cannot Be Edited

Created By: Christine Yee On 07/09/2026 at 07:42 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: BELLAIRE SENIOR CARE	FACILITY NUMBER: 195850501
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/09/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(f)(2)

Maintenance and Operation

(f) All waste shall be located, stored, and disposed of in a manner that will not transmit communicable diseases or odors, pose a risk to health and safety, or provide a breeding place or food source for insects or rodents. (2) Syringes and needles are disposed of in accordance with the California Code of Regulations, Title 8, Section 5193 concerning bloodborne pathogens. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview conducted with the Administrator, the licensee did not comply with the section cited above as per interview, the needles on pre-filled insulin pens were being disposed of in the trash can which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/16/2026
	Plan of Correction
1 2 3 4	The Licensee shall ensure that all needles are disposed of in a safe manner at all times. ****A sharps container was ordered and delivered by the pharmacy to the facility during this visit***

Type B

Section Cited

CCR

87608(a)(3)

Postural Supports

(a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions: (3) A written order from a physician indicating the need for the postural support shall be maintained in the resident's record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above as it was observed that Resident #2 had a half bedrail mounted on the front of the hospital bed and a full bedrail on the back of the bed and there was no written physicians order indicating the need for the postural support maintaind in the residents file, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/16/2026
	Plan of Correction
1 2 3 4	The Licensee will ensure that a written physician's order is obtained indicating the need for the postural supports prior to installing rails on residents' beds. Licensee will remove the full bedrail on the back of Resident #2's bed and obtain a written physican's order for the use of a half bedrail by 7/16/26

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: 07/09/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2026

LIC809 (FAS) - (06/04)

Page: 4 of 5

Document Has Been Signed on 07/09/2026 08:26 PM - It Cannot Be Edited

Created By: Christine Yee On 07/09/2026 at 07:42 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: BELLAIRE SENIOR CARE	FACILITY NUMBER: 195850501
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/09/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87609(b)(4)

Allowable Health Conditions and the Use of Home Health Agencies

(b) Incidental medical care may be provided to residents through a licensed home health agency provided the following conditions are met: (4) The licensee and home health agency agree in writing on the responsibilities of the home health agency, and those of the licensee in caring for the resident's medical condition(s). 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 does not have a written agreement with the home health agency on the responsibilities of the home health agency used by Resident #4 and those of the licensee which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/16/2026
	Plan of Correction
1 2 3 4	The Licensee agreed to contact the home health agency used by Resident #4 and obtain an agreement defining the responsibllities of the home health agency and the responsiblities of the Licensee and maintain in the resident's file by 7/16/26. *****a copy of the agreement was obtained via email during today's visit***

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: 07/09/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2026

LIC809 (FAS) - (06/04)

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