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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609496
Report Date: 04/08/2026
Date Signed: 04/08/2026 04:14:14 PM

Document Has Been Signed on 04/08/2026 04:14 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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:ENCINO TERRACE SENIOR LIVINGFACILITY NUMBER:
197609496
ADMINISTRATOR/
DIRECTOR:		ROSE YOUSEFIANFACILITY TYPE:
740
ADDRESS:16025 VENTURA BLVDTELEPHONE:
(818) 986-8466
CITY:ENCINOSTATE: CAZIP CODE:
91436
CAPACITY: 85CENSUS: 74DATE:
04/08/2026
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:28 PM
MET WITH:Rose Yousefian, Executive DirectorTIME VISIT/
INSPECTION COMPLETED:
04:25 PM
NARRATIVE
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This case management visit conducted by Licensing Program Analyst (LPA) Tihesha Smith and Licensing Program Manager (LPM) Naira Margaryan due to increased complaint volume, prior issues observed to include but not limited to insufficient staffing.

Upon arrival, licensing representatives observed the following:

· The facility did not have sufficient support staff.

· LPA Smith and LPM Margaryan observed no front desk staff present. They remained at the front desk for approximately 20–30 minutes before a maintenance worker arrived to assist.

· On 04/06/2026, LPM Margaryan conducted a follow-up call with the Executive Director (ED), who confirmed that the facility does not currently have an employee assigned to the front desk.

· The facility continued to lack adequate staffing to meet residents’ needs. During the licensing visit on 02/27/2026, LPA Smith and LPM Margaryan detected a strong urine odor in the elevator, third-floor hallways, and common areas. They observed a resident in a wheelchair who was wet and emitting an odor of urine, and/or feces. On the third floor and throughout the facility, only one caregiver was on duty to provide care and supervision for all residents.

NAME OF LICENSING PROGRAM MANAGER: Naira Margaryan
NAME OF LICENSING PROGRAM ANALYST: Tihesha Smith
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/08/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/08/2026
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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: ENCINO TERRACE SENIOR LIVING
FACILITY NUMBER: 197609496
VISIT DATE: 04/08/2026
NARRATIVE
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(cont from 809C) Based on observations and interviews with residents and staff, nine residents required extensive care. Three residents in wheelchairs, who required escort assistance, were left without supervision. At least one resident required a two-person assist for transfers in and out of bed/chairs/toileting and/or showering.

Emergency Plan Review

· The facility’s Emergency Plan of Operation was reviewed and requires updates.

· Non-ambulatory residents were observed on the third (3rd) floor, and it was not clear how staff would assist them during an emergency.

· To date, no updated emergency plan has been submitted to the Licensing office for review and approval.

Resident Records Review

· Residents’ records were incomplete and/or outdated.

· At least one (1) resident assessment contained conflicting information regarding the level of care required (e.g., bathing, toileting, dressing) when compared to medical assessments.

· At least one (1) resident file did not contain the Administrator’s/Director’s signature and date on required documents, including Resident Appraisals and Needs and Services Plans.

· No written notification was provided to the Licensing office verifying that all resident records had been updated and corrected. Deficiencies cited on the LIC 809D.

Exit interview conducted, appeal rights discussed, copy of the report given

NAME OF LICENSING PROGRAM MANAGER: Naira Margaryan
NAME OF LICENSING PROGRAM ANALYST: Tihesha Smith
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/08/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2026
LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 04/08/2026 04:14 PM - It Cannot Be Edited


Created By: Tihesha Smith On 04/08/2026 at 02:35 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., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: ENCINO TERRACE SENIOR LIVING
FACILITY NUMBER: 197609496

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/08/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/08/2026
Section Cited
CCR
87411(a)

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87411 Personnel Requirements – General. (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care [...] Additional staff shall be employed as necessary to perform office work[...]The licensing agency may require any facility to provide additional staff whenever it determines [...]the needs of particular residents
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Licensee/Administrator will provide hiring plan to LPA
POC: 04/09/26
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This requirement was not met based on licensing staff observation at time of visit which poses risk for residents in care.
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Type A
04/08/2026
Section Cited
CCR87212(a)2(A)

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87212 Emergency Disaster Plan. (a)Each facility shall have a disaster and mass casualty plan of action. The plan shall be in writing and shall be readily available.
(2) Plan for evacuation including: (A) Fire safety plan
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Licensee/Administrator will provide Emergency disaster plan to LPA
POC: 04/09/26
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This requirement was not met based on licensing staff observation at time of visit which poses risk for residents in care.
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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.
Naira Margaryan
NAME OF LICENSING PROGRAM MANAGER:
Tihesha Smith
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/08/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/08/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/08/2026 04:14 PM - It Cannot Be Edited


Created By: Tihesha Smith On 04/08/2026 at 02:50 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., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: ENCINO TERRACE SENIOR LIVING
FACILITY NUMBER: 197609496

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/08/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/17/2026
Section Cited
CCR
87506

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87506 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 licensing agency staff

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Licensee/Administrator will submit plan on how to ensure resident records update and readily available for review
POC: 04/17/26
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This requirement was not met based on licensing staff observation at time of visit which poses a potential risk for residents in care.
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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.
Naira Margaryan
NAME OF LICENSING PROGRAM MANAGER:
Tihesha Smith
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/08/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/08/2026


LIC809 (FAS) - (06/04)
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