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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610017
Report Date: 01/28/2025
Date Signed: 01/28/2025 01:14:29 PM

Document Has Been Signed on 01/28/2025 01:14 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:SHERWOOD FOREST SENIOR LIVINGFACILITY NUMBER:
197610017
ADMINISTRATOR/
DIRECTOR:		GOHAR AKASHYANFACILITY TYPE:
740
ADDRESS:8635 AMESTOY AVENUETELEPHONE:
(818) 626-8297
CITY:SHERWOOD FORESTSTATE: CAZIP CODE:
91325
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 6DATE:
01/28/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:35 AM
MET WITH:Gohar Akashyan, AdministratorTIME VISIT/
INSPECTION COMPLETED:
01:15 PM
NARRATIVE
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On 01/28/25 at 9:35AM, Licensing Program Analyst (LPA) Gina Saucedo, arrived to conduct an unannounced, annual inspection at the facility. Upon arrival, LPA Saucedo met with caregiver Luisine Piliposyan and disclosed the purpose of the visit. Gohar Akashyan, the administrator was present at the time.

LPA asked for the census, resident, and staff files.


A physical tour was conducted at 10:45AM and observed the following:



The Kitchen area was toured, and LPA observed there to be sufficient seven (7) day supply of non-perishable foods and perishable food for all residents. The kitchen area was clean at the time of the tour. There is a telephone line on the counter in the kitchen on your left-hand side. There is extra, food in the kitchen pantries. The knives are at the top of the kitchen counter on your right-side locked and inaccessible to the residents. The chemicals are under the sink locked and inaccessible to the residents.

The medications are locked and inaccessible to the residents in the pantry area on the other side of the facility.

Outside/Backyard: The outside/backyard has furniture for the residents with proper seating. There is a staff office where files are kept. It is locked and inaccessible to the residents. There is another shed on the left-side where there is extra items for the residents. The facility does have a signal system. The facility does not have a pool/body of water. The outside/backyard can be accessed from the kitchen area.

LIC 809C-continued
Troy AgardTELEPHONE: (818) 596-4334
Gina SaucedoTELEPHONE: (818) 304-3057
DATE: 01/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/28/2025
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: 01/28/2025
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The fire extinguisher is located against the wall on your left-hand side of the entrance of the facility. It is fully charged. The expiration date is 02/2025. There is another fire extinguisher located down the hallway in between the resident rooms. There is also a fire extinguisher located at the entrance of the kitchen on your right-hand side.

Bedrooms: There are five (5) bedrooms and two (2) full bathrooms. Four (4) bedrooms are single, occupied and (1) bedroom is shared. There is no staff room. All bedrooms and bathrooms were toured and were properly furnished and have appropriate bedding, linens, toiletry, and lightning. The bathrooms have proper toiletry, grab bars and non-skid mats. The bathroom temperatures of the water are within regulations reading at 110–112-degree Fahrenheit.

The dining/living room area has enough seating for the residents and the staff. There is a fireplace that is covered and inaccessible to the residents. There are two (2) dining room areas with a television. The first aid kit is on the counter area of one (1) of the dining halls.

The house temperature is at 75-degree Fahrenheit. There are several smoke detectors/carbon monoxides in the dining/living area that are operable.

Administrative: There is no annual fee that is due right now. The Insurance plan is dated as of 01/17/25. At the entrance of the facility against the left-side of the facility there is a billboard with signs: Yes, Ombudsman, Disaster Plan, Resident Rule, Theft and Loss, Designee, House Rules, Mitigation Plan and Hospice waiver. The fire drill was last performed on 12/2024.

Let it be noted, there has been changes to the original facility sketch and sent to Community Care Licensing Department. There is a Junior ADU-Accessory Dwelling Unit with a different address which has been approved by the Building Permit and LPA was able to do a physical tour. The Junior ADU has one (1) bedroom and one (1) bathroom. The facility now has five (5) bedrooms approved by the building permit. The building permit was approved and finalized in 12/2024. The Pre-Inspection Consultation Request Request has been submitted for payment.

An exit interview was conducted, no citation(s) were issued, and a copy of this report was given to the administrator.

SUPERVISOR'S NAME: Troy AgardTELEPHONE: (818) 596-4334
LICENSING EVALUATOR NAME: Gina SaucedoTELEPHONE: (818) 304-3057
LICENSING EVALUATOR SIGNATURE:

DATE: 01/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/28/2025
LIC809 (FAS) - (06/04)
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