197610017-5-2-2024-31-AS-GSAO-D4VP9K-20240502110717

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610017
Report Date: 05/02/2024
Date Signed: 05/02/2024 11:07:26 AM

Document Has Been Signed on 05/02/2024 11:07 AM - 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:	SHERWOOD FOREST SENIOR LIVING		FACILITY NUMBER:	197610017
ADMINISTRATOR:	GOHAR AKASHYAN		FACILITY TYPE:	740
ADDRESS:	8635 AMESTOY AVENUE		TELEPHONE:	(818) 626-8297
CITY:	SHERWOOD FOREST	STATE: CA	ZIP CODE:	91325
CAPACITY:	6	CENSUS: 6	DATE:	05/02/2024
TYPE OF VISIT:	Office	UNANNOUNCED	TIME BEGAN:	09:55 AM
MET WITH:	Gohar Akashyan		TIME COMPLETED:	11:15 AM

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An Informal Conference was conducted today at the Woodland Hills-South Adult and Senior Care Regional Office. This Informal Conference was held to discuss recent deficiencies and provide guidance to ensure future compliance.

Prior to the meeting, Licensee was given the chance to review the facility file.

Present at today's meeting were the following:

Artur Agabekyan,Licensee
Gohar Akashyan, Administrator
Lusine Pilipasyan, Employee
Troy Agard, Licensing Program Manager (LPM)
Gina Saucedo, Licensing Program Analyst (LPA)

The informal conference process was explained to the Licensee. The Licensee was also informed that this Informal Conference is a part of the administrative action process. Further citations may result in a Non-Compliance Conference, which could lead to a referral to the Department's Legal Division for possible license revocation or other administrative actions.

BRIEF HISTORY: The facility has been in operation since 03/03/2020.

LIC 809C-continued

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) 596-4334
LICENSING EVALUATOR NAME: Gina Saucedo	TELEPHONE: (818) 304-3057
LICENSING EVALUATOR SIGNATURE:	DATE: 05/02/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/02/2024

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

FACILITY NAME: SHERWOOD FOREST SENIOR LIVING	FACILITY NUMBER: 197610017
	VISIT DATE: 05/02/2024

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Today's conference was to address the following issues:

1) An updated fire clearance is needed.

2) The facility is at risk of losing their fire clearance due to unpermitted modification (renovations).

3) During a facility inspection, a back yard storage shed was observed to be used as an office space. Any space utilizing utilities (light, gas, water) needs to be permitted by Building and Grounds.

4) During a facility inspection, a fire door magnet kill switch was observed. Per the fire inspector, this needs to be removed as it was not done properly and nor was it permitted. Improper electrical wiring can result in a fire.

5) Additional smoke detectors in the area that were added were not permitted. Per the Fire inspector the entire facility electrical wiring needs to be checked and permitted.

Per the fire inspector, the order that is on file with building and safety needs to be corrected. It indicates the original plan was to add two (2) bedrooms however three (3) bedrooms were added instead. The original plans were given corrections, were subject for approval and permit.

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) 596-4334
LICENSING EVALUATOR NAME: Gina Saucedo	TELEPHONE: (818) 304-3057
LICENSING EVALUATOR SIGNATURE:	DATE: 05/02/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/02/2024

LIC809 (FAS) - (06/04)

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