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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609950
Report Date: 02/03/2025
Date Signed: 02/03/2025 03:02:37 PM

Document Has Been Signed on 02/03/2025 03:02 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:PRIME RESIDENTIAL SENIOR CAREFACILITY NUMBER:
197609950
ADMINISTRATOR/
DIRECTOR:		KHECHIKYAN, SOFYAFACILITY TYPE:
740
ADDRESS:19418 LANARK STREETTELEPHONE:
(818) 626-8553
CITY:RESEDASTATE: CAZIP CODE:
91335
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 7DATE:
02/03/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:38 AM
MET WITH:Sofya Khechikyan, AdministratorTIME VISIT/
INSPECTION COMPLETED:
03:45 PM
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At 9:30 AM Licensing Program Analysts (LPAs), Huma Rahimi and Nadia Shabazian, conducted an unannounced annual inspection at the facility mentioned above. LPAs met with the staff Anahit Zohrabyan and later Administrator Sofya Khechikyan arrived and explained the reason for the visit. Physical tour was conducted with the Administrator and LPAs observed the following:

The total capacity of the facility is approved for six (6) residents; however, LPAs observed seven (7) residents. LPAs were informed that one (1) of the residents is their family member.

Kitchen: At 9:45 AM LPAs toured the kitchen area and observed enough supplies of staple non-perishable for minimum 1 week and perishable for 2 days at the facility. All knives and sharps observed to be locked in a kitchen drawer. LPAs observed a fully charged fire extinguisher hanging on the wall by the kitchen purchased on 02/03/2025.

Medications: At 9:50 AM LPAs observed medications are centrally stored and locked closet in a hallway. Additionally, LPAs observed Hydrocortisone Ointment 2.5% in the kitchen drawer unlocked and as well as other medication and ointments in residents bedrooms unlocked and accessible to residents in care. Furthermore, at 2:30 PM, during the medication review for six (6) out of six (6) residents, LPAs could not verify the accuracy of the medication administration due to the lack of incomplete Centrally Stored Medication Destruction Form. Administrator informed LPAs that the Administrator did not complete the form and was unable to provide a reason.

Bedrooms: The facility has six (6) bedrooms in total. All bedrooms were clean and odorless. Furniture was in good repair. Bedroom #3 was designated for a bedridden resident, and the emergency exit was free from obstruction. Bedroom #6 is shared and one of the resident is a family member of the Administrator who requires full assistance with daily living. One of the bedrooms located near the kitchen is designated for staff and LPAs observed free of hazard and obstruction. LPAs also observed medication accessible to residents in their bedrooms. Continue on LIC 809C

Nichelle GillyardTELEPHONE: (818) 596-4370
Huma RahimiTELEPHONE: (818) 304-2399
DATE: 02/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/03/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: PRIME RESIDENTIAL SENIOR CARE
FACILITY NUMBER: 197609950
VISIT DATE: 02/03/2025
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Bathrooms: The facility had 3 bathrooms. Bathrooms #1 located by the entrance is designated for staff and LPAs observed a small cabinet with an Antibiotic Pain Ointment and Vicks accessible to residents in care. All bathrooms contained paper towels and liquid soap. Bathroom #3 attached to bedroom #6 has a trash can without tight fitting lid and as well LPAs observed scissors accessible to residents in care. Bathrooms have grab bars and a non-skid mat. Hot water temperature measured at 119.8°F.

Common Areas: The facility maintains a comfortable temperature at 75°F. The living room and dining area appeared clean and were properly furnished. The living room has a television, comfortable furniture. No obstructions and or tripping hazards throughout the facility.

Garage: LPAs entered an unlocked garage and saw more cleaning supplies, hazardous liquids, detergents, and extra PPE accessible to residents in care. LPAs observed an extra refrigerator for staff.

Laundry: The laundry is located between the kitchen and garage. LPAs observed an unlocked laundry detergent accessible to residents in the laundry room. Staff admitted to LPAs that they forgot to lock it away after using it this morning.

Outside and Back Yard: LPAs toured the two side paths and back yard. Both emergency exit gates were unlocked, and paths were free from debris. LPAs observed appropriate outdoor furniture, with a covered shaded area for residents. LPAs observed gardening tools and a full can of paint accessible to residents in care.

Smoke detectors/carbon monoxide. Smoke detectors were located throughout the facility, and at 10:00 AM, they were tested and observed to be operational. Carbon monoxide was living room and was also tested and observed to be operational. LPAs heard functioning auditory alarms on all exit doors.

Between 12:00 PM to 2:30 PM, LPAs reviewed records of four (4) residents and two (2) staff. Resident files were not updated/completed. Staff records and training were not updated and completed. .

During the interview with the Administrator LPAs were informed that one of the residents (R5) passed away on 09/05/2024. On or about 09/01/2024, R5 was taken to the hospital due to breathing problem and R5 passed away in the hospital. LPAs reviewed all incident and death reports in the system and did not observe any Incident or death reports regarding R5.

Continue on LIC 809C

SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4370
LICENSING EVALUATOR NAME: Huma RahimiTELEPHONE: (818) 304-2399
LICENSING EVALUATOR SIGNATURE:

DATE: 02/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2025
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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.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: PRIME RESIDENTIAL SENIOR CARE
FACILITY NUMBER: 197609950
VISIT DATE: 02/03/2025
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In addition, the Administrator admitted that no incident or death reports were submitted to the Regional Office (RO) since the Administrator forgot to submit an incident and death reports to the department. Based on Title 22 Regulation: a written Unusual Incident / Injury Report shall be submitted to CCLD within seven (7) days of occurrence. LPA informed the Administrator that all staff members are mandated reporters and they are all responsible for reporting.

Deficiencies cited during today’s visit. Appeal rights issued and given.

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

Administrative: LPAs collected Certificate of Liability Insurance, and LIC500.

SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4370
LICENSING EVALUATOR NAME: Huma RahimiTELEPHONE: (818) 304-2399
LICENSING EVALUATOR SIGNATURE:

DATE: 02/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2025
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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364


FACILITY NAME: PRIME RESIDENTIAL SENIOR CARE
FACILITY NUMBER: 197609950

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/03/2025
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
CCR
87204(a)
Limitations -Capacity and Ambulatory Status
(a) A licensee shall not operate a facility beyond the conditions and limitations specified on the license, including specification of the maximum number of persons who may receive services at any one time. An exception may be made in the case of catastrophic emergency when the licensing agency may make temporary exceptions to the approved capacity.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview , the licensee did not comply with the section cited above by going over capacity and there are seven (7) residents living at the facility which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/05/2025
Plan of Correction
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The Administrator agreed to relocate of the resident to a different location and submit the proof to LPA by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
Nichelle GillyardTELEPHONE: (818) 596-4370
Huma RahimiTELEPHONE: (818) 304-2399

DATE: 02/03/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/03/2025

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Document Has Been Signed on 02/03/2025 03:02 PM - It Cannot Be Edited

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: PRIME RESIDENTIAL SENIOR CARE
FACILITY NUMBER: 197609950

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/03/2025
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
CCR
87211(a)(1)A,B,&D
Requirements: (a) Each licensee shall furnish to the licensing agency such reports... (1) A written report shall be submitted to the licensing agency and to the person... ... any of the events specified in (A), (B) & (D)...
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above in not submitting an incident and death report for R5 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/10/2025
Plan of Correction
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Administrator agreed to submit an incident report and a death report for R5. Administrator will have to submit a statement of understanding about the above section and reporting requirements.
Type B
Section Cited
CCR
87506(a)
87506 Resident Records: (a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident...

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above. Resident records were incomplete and or missing signatures, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/10/2025
Plan of Correction
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icensee agreed to complete/update six (6) out of six (6) resident files and submit to LPA by the POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Nichelle GillyardTELEPHONE: (818) 596-4370
Huma RahimiTELEPHONE: (818) 304-2399

DATE: 02/03/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/03/2025

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Document Has Been Signed on 02/03/2025 03:02 PM - It Cannot Be Edited

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: PRIME RESIDENTIAL SENIOR CARE
FACILITY NUMBER: 197609950

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/03/2025
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
CCR
87309(a)
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in not locking all the laundry and other toxins locked and was observed accessible to residents in care which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/05/2025
Plan of Correction
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Administrator agreed to train the staff and submit the proof to LPA by due date.
Type A
Section Cited
CCR
87705(f)(1)
(f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in having scissors in the bathroom and gardening tools in the backyard unlocked and accessible to residents in care which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/05/2025
Plan of Correction
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Administrator also agreed to provide training to their staff and provide LPA with a proof by the due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Nichelle GillyardTELEPHONE: (818) 596-4370
Huma RahimiTELEPHONE: (818) 304-2399

DATE: 02/03/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/03/2025

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/03/2025 03:02 PM - It Cannot Be Edited

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: PRIME RESIDENTIAL SENIOR CARE
FACILITY NUMBER: 197609950

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/03/2025
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
CCR
87411(c)
87411 Personnel Requirements - General
(c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in two out of two staff not completed their annual required training which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/10/2025
Plan of Correction
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Administrator agreed to provide all required training to their staff and submit the proof to LPA by the due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
Nichelle GillyardTELEPHONE: (818) 596-4370
Huma RahimiTELEPHONE: (818) 304-2399

DATE: 02/03/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/03/2025

LIC809 (FAS) - (06/04)
Page: 7 of 8
Document Has Been Signed on 02/03/2025 03:02 PM - It Cannot Be Edited

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: PRIME RESIDENTIAL SENIOR CARE
FACILITY NUMBER: 197609950

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/03/2025
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
CCR
87465(h)(6)(F)
87465 Incidental Medical and Dental Care
(h) The following requirements shall apply to medications which are centrally stored: (6) The licensee shall be responsible for assuring that a record of centrally stored prescriptions... (A)...(F)...


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record reviews and interviews, licensee did not comply with the section above, as facility staff handling medications were not properly documenting prescribed medications on CSMDR, which poses an immediate health and safety risk to residents in care.
POC Due Date: 02/05/2025
Plan of Correction
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Administrator agreed to schedule vendorized training for all staff by 02/05/23 and submit to CCL the vendor information and scheduled date of training. Training certifications to be submitted to CCL upon completion.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
Nichelle GillyardTELEPHONE: (818) 596-4370
Huma RahimiTELEPHONE: (818) 304-2399

DATE: 02/03/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/03/2025

LIC809 (FAS) - (06/04)
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