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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195850634
Report Date: 05/28/2026
Date Signed: 05/28/2026 05:20:23 PM

Document Has Been Signed on 05/28/2026 05:20 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:VIKMED INCFACILITY NUMBER:
195850634
ADMINISTRATOR/
DIRECTOR:		GEVORGYAN,MANEFACILITY TYPE:
740
ADDRESS:7459 SYLMAR AVENUETELEPHONE:
(747) 257-9540
CITY:VAN NUYSSTATE: CAZIP CODE:
91405
CAPACITY: 6CENSUS: 5DATE:
05/28/2026
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:46 AM
MET WITH:Lilit MkhitaryanTIME VISIT/
INSPECTION COMPLETED:
05:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Christine Yee conducted an unannounced case management visit due to deficiencies observed on today's visit. LPA Yee was let into the home by Alisa Arshakyan, Staff contacted Mane Gevorgyan, Licensee and Lilit Mkhitaryan, Staff. Lilit Mthitaryan arrived at 11:08am to conduct the visit. Per information provided, Mane Gevorgyan, Licensee is present at the facility on Tuesdays. The reason for today's visit was provided.

On today's visit, LPA Yee observed the following deficiencies:
  • Liana Martirosyan, new Applicant, does not have evidence that a request for a criminal record transfer was submitted and works at the facility on Sunday, Thursday on Friday. Lilit Mkhitaryan, is currently not associated to the facility and was not cited on today's visit pending verification of receipt of a Criminal Record Clearance Transfer submitted in February 2026. A return visit will be conducted if needed.
  • Liana Martirosyan and Mane Gevorgyan do not have files available at the facility for Department review.
  • Resident #5 was placed on hospice palliative care 20 days ago and has a wound on the right calf and on the lower back and there is no hospice care plan in place, no evidence of training by the nurse, no agreement with the hospice agency and the Department was not notified of the initiation within 5 day of initiation. .
Licensee will provide a copy of the LIC500 with names of staff and staff schedule by 6/4/26.
Deficiencies were cited under California Code of Regulations, Title 22, Division 6, Chapter 8. Immediate civil penalties were assessed.

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: 05/28/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/28/2026
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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Document Has Been Signed on 05/28/2026 05:20 PM - It Cannot Be Edited


Created By: Christine Yee On 05/28/2026 at 10:57 AM
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: VIKMED INC
FACILITY NUMBER: 195850634

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/28/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/29/2026
Section Cited
CCR
87355(e)(3)

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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: (3) 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 have received a criminal record clearance and have requested a criminal record transfer prior to being present at the facility. Facility will submit a written statement as to how they will come into compliance or associate Liana Martirosyan on Guardian by 5/29/26 or
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This requirement was not met as evidenced by: Per file review, Liana Mirtarosyan, Applicant is not associated to the facility and works on Sunday, Thursday and Friday at the facility
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complete an LIC9182 with a legible copy of a government document, such as a driver license to have Liana Martirosyan associated by 5/29/26
Type B
06/04/2026
Section Cited
CCR87412(f)

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Personnel Records:All personnel records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. Records may be removed if necessary for copying. Removal of records shall be subject to the following requirements:
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The Licensee will ensure that all staff and residents' files are maintained at the facility and made available within a reasonable time for Department review. Licensee will ensure that a copy of Mane Gevorgyan and Liana Martirosyan files are maintained on the premises by 6/4/26.
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This requirement was not met as evidenced by: Mane Gevorgyan and Liana Martirosyan's files were not available for reivew when requested. Mane Gervorgyan's file was at her residence and Liana's file was at Lilit's residence.
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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.
Kristin Heffernan
NAME OF LICENSING PROGRAM MANAGER:
Christine Yee
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/28/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/28/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/28/2026 05:20 PM - It Cannot Be Edited


Created By: Christine Yee On 05/28/2026 at 03:07 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: VIKMED INC
FACILITY NUMBER: 195850634

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/28/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/04/2026
Section Cited
CCR
87633(a)(4)

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Hospice Care of Terminally Ill Residents: The licensee shall be permitted to accept or retain residents who have been diagnosed as terminally ill by his or her physician and surgeon and who may or may not have restrictive and/or prohibited health conditions, to reside in the facility and
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Licensee will review Title 22 Section 87633 Hospice Care of Terminally III Residents and submit a written statement that the section was read and the facility will adhere to the condition required to retain a terminally ill resident. Also provide evidence that all the required documents, training,care plan
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receive hospice services..when all the conditions are met. A written hospice care plan which specifies the care, services, and necessary medical intervention related to the terminal illness as necessary to supplement the care and supervision provided by the facility is developed for each terminally ill resident or ....
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and agreements have been obtain for Resident #5 and maintained on site for review by 6/4/26
Type B
06/04/2026
Section Cited
CCR87632(d)(2)

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Hospice Care Waiver: If the Department grants a hospice care waiver it shall stipulate terms and conditions of the waiver as necessary to ensure the well-being of terminally ill residents ...The licensee shall notify the Department in writing within five working days of the initiation of hospice care
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Licensee will ensure that the conditions noted in the approved Hospice Waiver granted is adhered to. The licensee will submit a written notifiication of hospice initiation to the Department for Resident #5 by 6/4/26.
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for any terminally ill resident in the facility or within five working days of admitting a resident already receiving hospice care services. The notice shall include the resident's name and date of admission to the facility and the name and address of the hospice. Facility did not report hospice initiation for Resident #5
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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.
Kristin Heffernan
NAME OF LICENSING PROGRAM MANAGER:
Christine Yee
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/28/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/28/2026


LIC809 (FAS) - (06/04)
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