197610002-8-11-2026-29-AS-CYEE-DWV2NT-20260811173316

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610002
Report Date: 08/11/2026
Date Signed: 08/11/2026 05:34:05 PM

Document Has Been Signed on 08/11/2026 05:34 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 N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	JASMINE		FACILITY NUMBER:	197610002
ADMINISTRATOR/ DIRECTOR:	SARGSYAN, ARMAN		FACILITY TYPE:	740
ADDRESS:	7331 KATHERINE AVE		TELEPHONE:	(818) 785-4230
CITY:	VAN NUYS	STATE: CA	ZIP CODE:	91405
CAPACITY: 6		CENSUS: 4	DATE:	08/11/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	10:33 AM
MET WITH:	Jasmine Sargsyan, Licensee		TIME VISIT/ INSPECTION COMPLETED:	05:40 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	Licensing Program Analyst(LPA) Christine Yee conducted an unannounced required Annual Inspection using the complete CARE Inspection Tool. LPA Yee was let into the home by Gayane Yeghiazaryan, Staff. Jasmine Sargsyan, Licensee was contacted by staff and she arrived at 11:17am to conduct the visit. The reason for today's visit was provided. Arman Sargsyan, Administrator did not participate in today's visit.. The facility is a single storey family home consisting of a living room, dining room, kitchen, 3 bedrooms, 3 full bathrooms and a attached garage that was converted into a office/living quarters. The facility is fire cleared for 6 non-ambulatory residents only. On today's visit, all 12 domains of the CARE Inspection Tool was reviewed, 4 resident and 6 staff files were reviewed. The following were observed: the living room, dining room and kitchen were furnished and equipped with the appropriate furniture and equipment for its designated use and for the licensed capacity. The fire place located in the front room was observed with a fire screen. Bedroom #1 is currently rented as a private room and is furnished with 1 hospital bed, equipped with half bed rails, a night stand, a lamp, a chair, a dresser and a built in closet. Per Licensee, the second set of required furniture is in storage and will be provided if the room reverts back to a shared room. Bedroom #2 and Bedroom #3 are furnished with 2 each of the following: 2 hospital beds, 2 chairs, 2 night stands, 2 lamps, 2 dressers and a shared built in closet. The bed located to the right in bedroom #2 and the 2 hospital beds in bedroom #3 are equipped with a half bed rail. There are no written continued on LIC809-C

Kristin Heffernan
Christine Yee
	DATE: 08/11/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2026

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 N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: JASMINE	FACILITY NUMBER: 197610002
	VISIT DATE: 08/11/2026

NARRATIVE

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physicians order on file to indicate the need for any of the bed rails observed. A written physicians order was obtained for Resident #1 and Resident #3 and the 1/2 bed rails were removed from the two beds located in bedroom #3 during the visit.
Window dressings were observed on all the windows for privacy.
Linens were observed on the residents' beds as per personal preference and extra linens, blanket and towels were observed in the hallway linen closet. Also located in the hallway is a closet used to store hygiene products and detergent and cleaning solutions.
All 3 common bathrooms are equipped with a walk in shower, a toilet and a single sink vanity. The common bathroom(#1) located between bedroom #2 and bedroom #3 and the one located closest to the living room(#2) were observed with grab bars, a shower chair, toilet risers and a slip resistant mats. The common bathroom by the front door(#3) is designated for staff use and does not have grab bars or slip resistant mat. Water temperature read 112.0 degrees in bathroom #1, 108.7 in bathroom #2 and 113.8 degrees in bathroom #3.
Per review of the food supply, stored in the kitchen cabinets, there is sufficient perishable foods for a minimum of 2 days and sufficient non-perishable foods for a minimum of 7 days observed maintained on the premises.
Current general liability insurance was reviewed and met Title 22 requirements
Medications are centrally stored in a locked metal cabinet located in the dining room.
The auditory devices on the four outside exiting doors - 2 in living room, front door and bedroom #3 were all tested and were operational.
The only fire extinguisher located in the laundry room was last serviced on 6/23/26.
The washer and dryer was observed being used during the visit. Paper goods, such as toilet paper, paper towels were also stored in the second closet.
The hardwired smoke detectors and the only combination smoke/carbon monoxide detector located in the resident hallway were tested and were operational. Clarification will be obtained regarding the use of door stoppers on the fire rated bedroom doors.

continued on LIC809-C

NAME OF LICENSING PROGRAM MANAGER: Kristin Heffernan
NAME OF LICENSING PROGRAM ANALYST: Christine Yee
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 08/11/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2026

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 N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: JASMINE	FACILITY NUMBER: 197610002
	VISIT DATE: 08/11/2026

NARRATIVE

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LPA Yee verified with the Licensee that the facility telephone number on the facility profile has not changed.
The first aid kit was reviewed and met Title 22 requirements. First aid manual was observed.
All staff have current first aid training.
The attached garage, located in the front is still used as an office
The backyard has a gazebo furnished with chairs and a coffee table for resident activities. Also located in the backyard are 3 storage sheds used to store supplies.
Trash cans stored in the front yard were observed to be tightly sealed.
Overall, the inside and outside of the facility was observed to be clean and well maintained.

Deficiencies cited under California Code of Regulations, Title 22, Division 6, Chapter 8.

Exit interview was conducted, Appeals Rights discussed and a copy was provided.

NAME OF LICENSING PROGRAM MANAGER: Kristin Heffernan
NAME OF LICENSING PROGRAM ANALYST: Christine Yee
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 08/11/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2026

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 08/11/2026 05:34 PM - It Cannot Be Edited

Created By: Christine Yee On 08/11/2026 at 05:04 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. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: JASMINE	FACILITY NUMBER: 197610002
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/11/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87608(a)(3)

Postural Supports

(a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions: (3) A written order from a physician indicating the need for the postural support shall be maintained in the resident's record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order. 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 as it was observed during the visit that the beds of Resident #1, Resident #2, Resident #4 were equipped with 1/2 bed rails and there were not written physicians order on file to indicate the need for the bed rails which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/18/2026
	Plan of Correction
1 2 3 4	The Licensee will ensure that a written physcian's order indicating the need for the postural support is obtained and maintained in the residents' files prior to the use of any postural support. Licensee will contact the residents' physicians to obtain the written doctor's order by 8/18/26. ******** A written physician's order was obtained for Resident #1, Resident #3 and the 1/2 bedrails were removed from the beds in bedroom #3 during this visit************

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.

	Kristin Heffernan
NAME OF LICENSING PROGRAM MANAGER:

	Christine Yee
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/11/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2026

LIC809 (FAS) - (06/04)

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