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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609640
Report Date: 05/16/2025
Date Signed: 05/16/2025 01:35:30 PM

Document Has Been Signed on 05/16/2025 01:35 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 S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:MIRACLE ASSISTED LIVING FACILITYFACILITY NUMBER:
197609640
ADMINISTRATOR/
DIRECTOR:		GAYANE AGHABEKYANFACILITY TYPE:
740
ADDRESS:20648 LONDELIUS STTELEPHONE:
(747) 206-5390
CITY:WINNETKASTATE: CAZIP CODE:
91306
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 5DATE:
05/16/2025
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Gayane Aghabekyan - AdministratorTIME VISIT/
INSPECTION COMPLETED:
01:15 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
At 9:30am, Licensing Program Analyst (LPA) Perchui Milena Khurshudyan conducted an unannounced Case Management- Legal/Non-compliance visit. Upon arrival LPA met with the Caregiver Gayane Nersesyan, showed the department badge and explained the reason for the visit. Administrator Gayane Aghabekyan arrived shortly after and helped with physical plant walkthrough and resident/staff files. Entrance interview conducted.

On 7/30/2024, a Non-Compliance Conference (NCC) was held at the Regional Office (RO) to discuss complaint # 31-AS-20211116143735 and other facility deficiencies. Attendees included Regional Manager, Angela Whittaker; Licensing Program Manager, Eva Miller; Licensing Program Analysts Perchui Milena Khurshudyan, Mariana Agban, Licensee Bagrat Vahramyan, Administrator Gayane Aghabekyan, and Administrator Designee Rima Agaronyan. As a result of that NCC, the facility was placed on a two-year compliance plan.


At that time, Regional Manager (RM) and Licensing Program Manager (LPM) advised the Administrator should strive to remain in full compliance Relevant Title 22 Regulations.

The purpose of today’s visit is to conduct thorough inspection to ensure compliance.
LPA conducted a physical plant tour to ensure the health and safety of the clients and that the physical plant was in compliance with CA Title 22 Regulations.

Today’s focus was staff and resident records for accuracy, required documentation for Exception Requests, Residents health condition.
Continue on LIC809-C
Nichelle GillyardTELEPHONE: (818) 596-4370
Perchui KhurshudyanTELEPHONE: (818) 439-7073
DATE: 05/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/16/2025
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: MIRACLE ASSISTED LIVING FACILITY
FACILITY NUMBER: 197609640
VISIT DATE: 05/16/2025
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
At approximately 10:15am, LPA requested staff and resident records.
LPA was informed that the facility currently has five (5) residents and five (5) staff members. During today's visit LPA observed two (2) staff members on duty. LPA also checked the Licensing Information System (LIS) and observed that staff members/Caregivers are associated with this facility and the fingerprints are cleared.

LPA interviewed all residents, and all residents confirmed they feel happy, they love the facility, and have no concerns regarding food, staff and/or the care they receive in the facility.

Resident Files: At 11:00am LPA conducted resident and staff records review. The following was observed. Five (5) out of five (5) residents’ files were updated and complete. All required forms were present.

Staff Files: The Administrator stated that the facility currently has five (5) staff members. LPA observed all files were complete and updated.

Medication: LPA checked centrally stored medications stored locked inside the commercial cabinet located in the office area. All medications have Physician’s orders.

Facility was in compliance, thus, no deficiencies were identified and issued during today’s visit.

Exit interview conducted, copy of this report signed and delivered.

SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4370
LICENSING EVALUATOR NAME: Perchui KhurshudyanTELEPHONE: (818) 439-7073
LICENSING EVALUATOR SIGNATURE:

DATE: 05/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2025
LIC809 (FAS) - (06/04)
Page: 3 of 3