197609889-10-22-2026-31-AS-NRED-DZ4R67-20261022124417

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609889
Report Date: 10/22/2026
Date Signed: 10/22/2026 12:44:58 PM

Document Has Been Signed on 10/22/2026 12:44 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.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	PEARL OF WEST HILLS, INC		FACILITY NUMBER:	197609889
ADMINISTRATOR/ DIRECTOR:	IRINA, KARBACHINSKIY		FACILITY TYPE:	740
ADDRESS:	23427 VICTORY BLVD		TELEPHONE:	(818) 854-6306
CITY:	WEST HILLS	STATE: CA	ZIP CODE:	91307
CAPACITY: 6		CENSUS: 4	DATE:	10/22/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:34 AM
MET WITH:	Irina Karbachinskiy		TIME VISIT/ INSPECTION COMPLETED:	12:55 PM

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At approximately 9:30 a.m. on 10/22/26, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced annual inspection. LPA met with the licensee and disclosed the reason for the visit.

The facility was last visited on 07/10/25 for a complaint visit. It is a single story building with four (04) bedrooms, three (03) bathrooms, kitchen, common areas, and outdoor areas. It has an approved fire clearance for six (06) non-ambulatory residents, of which one (01) may be bedridden in Bedroom #4. The facility serves residents with dementia. Approved hospice waivers for six (06).

At the main entrance, LPA observed postings for COVID precautions, personal rights, rights of resident councils, family councils, neighborhood complaint procedures, theft and loss policy, visitation policy, non-discrimination notice, facility sketch and license, confidential complaint contacts, ombudsman contacts, and administrator certificate. LPA observed the posted administrator certificate was expired. A record review conducted at 11:30 a.m. revealed the last valid administrator certificate expired on 08/08/26. Interview with the administrator at 11:30 a.m. revealed they were nearly finished with the renewal process. A deficiency is cited for an expired administrator certificate on the corresponding LIC 809-D page.

Walls, floors, windows, screens, and blinds were clean and in good repair. At 9:45 a.m. LPA measured the room temperature to be 72 degrees Fahrenheit. Puzzles, board games, and art supplies were provided in the living room. At 9:50 a.m., LPA observed one (01) resident coloring in the living room. At approximately 10:00 a.m., LPA observed a fully charged fire extinguisher near the stove. A receipt was attached from 03/06/26. At 10:10 a.m. LPA and S1 tested all auditory alarms. Three (03) out of three (03) auditory alarms were operational.

Naira Margaryan
Nicholas Reed
	DATE: 10/22/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/22/2026

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
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: PEARL OF WEST HILLS, INC	FACILITY NUMBER: 197609889
	VISIT DATE: 10/22/2026

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The facility has three (03) bathrooms. One (01) bathroom is private to Bedroom #4, and two (02) are shared. Two (02) out of two (02) resident bathrooms contained liquid soap, paper towels, handwashing instruction sign, trash can with a tight fitting lid, grab bars near the toilet and shower or a commode, and a non-skid surface in the shower. At approximately 10:30 a.m. LPA measured the water temperature in the bathroom near the main entrance to be 105.3 degrees Fahrenheit.

The facility has four (04) bedrooms. Two (02) bedrooms are private and two (02) are shared. All bedrooms contained a chair, lamp, nightstand, storage, and a bed with adequate bedding. All furnishings were clean and in good condition. LPA observed an adequate supply of perishable and non-perishable foods in the refrigerator and pantry. The stove hood was clean. Appliances were in good condition. Sharps were locked below the counter. Cleaning solutions were locked in a closet near the kitchen. Medications and a complete first aid kit were locked above the washer and dryer. The washing machine and dryer were located in the kitchen. Both were in working order. LPA observed a patio area in the rear of the facility. The patio contained furniture in good condition. Ramps leading out of the living room and Bedroom #4 were secure. The emergency exit path was free from obstructions. Two (02) out of two (02) exit gates were unlocked. At approximately 11:30 a.m. LPA reviewed resident and personnel files. All files were available for audit.

No immediate health or safety concerns were observed during today’s visit.

Exit interview conducted. Appeal rights discussed. Copy of report provided.

NAME OF LICENSING PROGRAM MANAGER: Naira Margaryan
NAME OF LICENSING PROGRAM ANALYST: Nicholas Reed
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 10/22/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/22/2026

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 10/22/2026 12:44 PM - It Cannot Be Edited

Created By: Nicholas Reed On 10/22/2026 at 12:29 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: PEARL OF WEST HILLS, INC	FACILITY NUMBER: 197609889
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/22/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87407(a)

87407 Administrator Recertification Requirements (a) Administrators shall complete at least forty (40) classroom hours of continuing education during each two (2)-year certification period, including. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above in not renewing their administrator certificate prior to the expiration date whiich poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/02/2026
	Plan of Correction
1 2 3 4	Licensee discussed and agreed to schedule all administrator classes by the POC due date and complete the required classes within the month.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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:

	Nicholas Reed
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/22/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/22/2026

LIC809 (FAS) - (06/04)

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