<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608215
Report Date: 07/08/2025
Date Signed: 07/08/2025 11:58:37 AM

Document Has Been Signed on 07/08/2025 11:58 AM - 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 S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:PACOIMA ADCFACILITY NUMBER:
197608215
ADMINISTRATOR/
DIRECTOR:		VERJINE EGIANFACILITY TYPE:
775
ADDRESS:13117 VAN NUYS BLVDTELEPHONE:
(818) 434-0004
CITY:PACOIMASTATE: CAZIP CODE:
91331
CAPACITY: 90CENSUS: 51DATE:
07/08/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:VERJINE EGIAN- AdministratorTIME VISIT/
INSPECTION COMPLETED:
12:20 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
On 7/08/2025 at approximately 9:00 AM, Licensing Program Analyst (LPA), Angelica Segovia conducted an unannounced annual visit to the facility. LPA was greeted by the Administrative Assistant, Haroutiun Boulanikian and stated the reason for their visit. The Administrator, Verjine Egian arrived shortly after to assist with today’s visit.

LPA asked for Census, Staff and Client Rosters. LPA conducted a physical plant tour at approximately 11:00 AM and the following was noted:

There are two entrances being utilized at the facility. One located within the front of the facility and the other located within the back. The facility is a single unit building with Administrative/staff offices, activity rooms, bathrooms and kitchen. The facilities capacity is ninety (90) clients, and during the inspection, forty-four (44) clients were present. The licensed facility has a fire clearance for eighty-one (81) ambulatory clients and nine (9) non-ambulatory clients. The facility is vendor through North Los Angeles Regional Center (NLARC). The screening area was observed to be located immediately upon entrance. Sign in sheet, hand sanitizer, gloves and masks are available.

Common areas: The common areas include the activity area, media area, resting area, arts/craft area, lunchroom, bathrooms, kitchen and Administrative/staff offices. The common areas were observed to be neat, clean and organized. LPA observed all rooms to be properly furnished and in good repair. The facility maintains a comfortable temperature at 72°F. Multiple working telephones were observed. (continued on LIC 809-C)
NAME OF LICENSING PROGRAM MANAGER: Troy Agard
NAME OF LICENSING PROGRAM ANALYST: Angelica Segovia
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/08/2025
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 3
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 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: PACOIMA ADC
FACILITY NUMBER: 197608215
VISIT DATE: 07/08/2025
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
Fire extinguishers were observed to be located throughout the facility and dated 5/29/2025. The facility was last inspected for maintenance and operational use of all fire/carbon monoxide alarms on 6/18/2025. The last Fire Drill was conducted on 6/13/2025. The Emergency and Disaster Plan was observed to be readily available with all proper information listed. Required postings: LPA observed required postings such as Personal Rights, Facility License and Emergency Disaster Plan located throughout the common areas.

Kitchen: The kitchen was observed to be clean and inaccessible to pests. The kitchen was observed to be equipped with appropriate fixtures. Lunch is provided by the program including snacks. The kitchen appliances were observed to be working and in proper condition. Sufficient supplies of disposal cups/plates were observed. The knives/sharps were observed to be kept locked in kitchen cabinet. The cleaning solutions/toxins were observed to be kept locked underneath the kitchen sink.

Bathrooms: The bathrooms were checked for cleanliness, proper operation and handicap accessibility. The hot water temperature was measured within regulations.

Storage Room: LPA observed cleaning solutions and toxins to be kept locked in back storage closet.

Outside: The outside of the facility is equipped with a shaded area for clients. No bodies of water located at this facility.

First-aid kit observed to be equipped with but not limited to bandages, scissors, digital thermometer, tweezer and First-aid manual.

Client/Staff Records: LPA conducted a complete file review of Client records. Client records appeared to be complete and updated. Staff records: LPA conducted a complete file review of staff records. Staff records appeared to be complete and updated. The medications, staff and client files were observed to be kept in locked filing cabinets located within the staff/administrative offices and inaccessible to clients.

There were no immediate health and safety hazards observed during the day of inspection. Exit interview conducted and a copy of this report was provided to the Administrator.

NAME OF LICENSING PROGRAM MANAGER: Troy Agard
NAME OF LICENSING PROGRAM ANALYST: Angelica Segovia
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2025
LIC809 (FAS) - (06/04)
Page: 3 of 3