195850548-7-7-2025-29-AS-QHUH-DJCV89-20250707161221

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 195850548
Report Date: 07/07/2025
Date Signed: 07/07/2025 04:12:34 PM

Document Has Been Signed on 07/07/2025 04:12 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:	VITA LIVING		FACILITY NUMBER:	195850548
ADMINISTRATOR/ DIRECTOR:	NAZARYAN, DAVIT		FACILITY TYPE:	740
ADDRESS:	15434 LA MAIDA ST		TELEPHONE:	(424) 777-7377
CITY:	SHERMAN OAKS	STATE: CA	ZIP CODE:	91403
CAPACITY: 6		CENSUS: 4	DATE:	07/07/2025
TYPE OF VISIT:	Post Licensing	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	01:05 PM
MET WITH:	Davit Nazaryan - Licensee		TIME VISIT/ INSPECTION COMPLETED:	04:30 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) Quoc Huynh arrived at the facility unannounced to conduct a post-licensing visit at 1:05PM. The LPA met with the Licensee Davit Nazaryan and explained the reason for the visit. Entrance interview conducted. Beginning at 1:10PM, the LPA and the Licensee toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The following was observed: GARAGE: The LPA observed the attached garage which was converted into an office space. The garage also contained emergency water, cleaning supplies, extra facility supplies, and general storage. COMMON AREAS: At the time of the visit, living room and dining room furniture was observed to be in good condition. There was a fireplace in the living room, which was observed to be screened and inaccessible. The facility’s hallways had extra cabinet space which stored emergency food, extra supplies, and extra linens. A laundry closet was observed with locked cabinets that contained detergent and cleaning supplies. Laundry machines were observed to be operational. The facility maintained a comfortable temperature throughout the visit. Required postings were observed near the garage door. Report Continued on LIC 809-C

NAME OF LICENSING PROGRAM MANAGER: Kristin Heffernan
NAME OF LICENSING PROGRAM ANALYST: Quoc Huynh
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 07/07/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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

FACILITY NAME: VITA LIVING	FACILITY NUMBER: 195850548
	VISIT DATE: 07/07/2025

NARRATIVE

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BEDROOMS/RESTROOMS: There are four (4) total bedrooms: two (2) private and two (2) shared. Bedroom #4 had a direct exit to the outside and was approved for one (1) bedridden resident. Bedrooms were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. There were three (3) total restrooms in the facility: one (1) private restroom, one (1) shared resident restroom located in the hallway, and one (1) visitor restroom located in the hallway. Restrooms were clean and sanitary and in operating condition with grab bars and non-slip surfaces. All restrooms were sufficiently stocked with soap and paper products. Cabinets under the sinks were observed to be locked and contained hygiene products. Hot water was tested and measured at 111.4 degrees F, which is within the required range.

OUTDOOR AREA: The outdoor area consisted of one (1) courtyard located in the middle of the property which led to the rear outdoor area. Both areas were observed to have patio furniture in good condition with shade, a grill in the rear area, and a locked shed in the courtyard that contained cleaning equipment. There were two (2) side gates: one (1) remained locked and contained facility storage, and one (1) side gate is used for emergencies and had a self-latching mechanism. No bodies of water noted, and exits were free of obstructions.

KITCHEN: Knives were stored inaccessible in a locked drawer near the sink. Cleaning supplies were stored inaccessible and locked under the sink. Kitchen appliances were clean and in operable condition. The facility had a sufficient supply of perishable and non-perishable food. Food in the refrigerator was observed to be properly stored with labels and dates. One (1) fire extinguisher was observed in the kitchen and was recently purchased and fully charged.

RECORDS: Record review began at 1:42PM. Resident records were reviewed for, but not limited to care plans, physician's report, admissions agreement, and consent forms. All records were in order. Personnel records were reviewed for, but not limited to health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All files were in order.

Report Continued on LIC 809-C

NAME OF LICENSING PROGRAM MANAGER: Kristin Heffernan
NAME OF LICENSING PROGRAM ANALYST: Quoc Huynh
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 07/07/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2025

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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

FACILITY NAME: VITA LIVING	FACILITY NUMBER: 195850548
	VISIT DATE: 07/07/2025

NARRATIVE

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INFECTION CONTROL/EMERGENCY DISASTER PLAN: During today's visit, LPA reviewed the facility's infection control plan and emergency disaster plan. Both documents were observed to be complete and reviewed annually as required. Emergency disaster drills are conducted quarterly, with the last documented drill on 06/13/2025. Smoke and carbon monoxide detectors were tested at 1:33PM and were operational at the time of the visit.

MEDICATIONS: Medication review began at 3:10PM. Medications were centrally stored and kept inaccessible in the dining room cabinet. Medications were observed for one (1) resident. Medications were labeled and checked for expiration dates. Medications were properly documented on the centrally stored medications and destruction record. No errors observed during the medication review.

No deficiency cited. Exit interview conducted. A copy of today's report was reviewed and provided.

NAME OF LICENSING PROGRAM MANAGER: Kristin Heffernan
NAME OF LICENSING PROGRAM ANALYST: Quoc Huynh
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 07/07/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2025

LIC809 (FAS) - (06/04)

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