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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609927
Report Date: 09/01/2021
Date Signed: 09/01/2021 03:29:29 PM

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:ASSISTED SENIOR CARE FACILITYFACILITY NUMBER:
197609927
ADMINISTRATOR:ANZHELIKA, ALIKHANYANFACILITY TYPE:
740
ADDRESS:7039 CLAIRE AVETELEPHONE:
(818) 988-9724
CITY:RESEDASTATE: CAZIP CODE:
91335
CAPACITY:6CENSUS: DATE:
09/01/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Anzhelika AlikhanyanTIME COMPLETED:
03:35 PM
NARRATIVE
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Licensing Program Analyst (LPA) Melissa Ruiz conducted an unannounced Case Management visit in order to address deficiencies observed during a complaint investigation (control # 31-AS-20210825122154).

LPA was greeted by staff member and requested the name of staff member. LPA Ruiz conducted a Criminal Background Check Clearance and Association on the Licensing Information System (LIS). Upon doing so, LPA discovered staff #1 is not associated to the facility. LPA spoke to Administrator, Anzhelika Alikhanyan regarding LPA’s findings and Administrator stated they were under the impression S1 had cleared the background check and was associated to the facility.

Deficiencies and Civil penalties were issued per CA code of Regulations Title 22 or Health and Safety Code. See 809D's included with this report.
Appeal rights issued.
Exit interview conducted
SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Melissa RuizTELEPHONE: (818) 401-7980
LICENSING EVALUATOR SIGNATURE:

DATE: 09/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2021
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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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: ASSISTED SENIOR CARE FACILITY
FACILITY NUMBER: 197609927
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/01/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/03/2021
Section Cited

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(a) The Department shall conduct a criminal record review of all individuals specified in Health and Safety Code section 1569.17 and shall have the authority to approve or deny a facility license, or employment, residence, or presence in the facility, based upon the results of such review.
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This requirement is not met as evidenced by:
Based on record review, the licensee did not comply with the section cited above in which staff member was not associated with the facility, which poses an immediate health, safety or personal rights risk to persons in care.
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This is a Zero Tolerance violation, therefore , Civil penalty in the amount of $500 dollars has been issued.

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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.
SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Melissa RuizTELEPHONE: (818) 401-7980
LICENSING EVALUATOR SIGNATURE:
DATE: 09/01/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/01/2021
LIC809 (FAS) - (06/04)
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