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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610051
Report Date: 07/02/2025
Date Signed: 07/02/2025 04:50:38 PM

Document Has Been Signed on 07/02/2025 04:50 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:VALLEY VILLAGE SENIOR LIVING, INC.FACILITY NUMBER:
197610051
ADMINISTRATOR/
DIRECTOR:		AYVAZYAN, SARGISFACILITY TYPE:
740
ADDRESS:5541 VANTAGE AVE.TELEPHONE:
(747) 253-0007
CITY:VALLEY VILLAGESTATE: CAZIP CODE:
91607
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 6DATE:
07/02/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:55 AM
MET WITH:Sargis Ayvazyan - LicenseeTIME VISIT/
INSPECTION COMPLETED:
05:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Quoc Huynh arrived at the facility unannounced to conduct a required annual visit at 8:55AM. The LPA was greeted by Staff, informed them of the reason for the visit, and Staff proceeded to notify the Licensee. The Licensee Sargis Ayvazyan arrived at 9:58AM. Entrance interview conducted.

Beginning at 10:30AM, the LPA and the Licensee toured the physical plant areas inside and outside to ensure there are no health and safety hazards, and the facility is in compliance with Title 22 Regulations. The following was observed:

KITCHEN: Knives were stored inaccessible in a locked drawer near the dishwasher. Cleaning supplies were located under the sink in a locked cabinet. Kitchen appliances were clean and in operable condition. Food in the refrigerator was observed to be properly stored with labels and dates. Emergency food and water was located in a cabinet above the refrigerator. Hot water was tested and measured at 118.6 degrees F. LPA observed one (1) fire extinguisher that was purchased on 07/11/2024 and a first aid kit mounted on the wall.

Report Continued on LIC 809-C
Kristin HeffernanTELEPHONE: (818) 593-4493
Quoc HuynhTELEPHONE: (323) 313-4746
DATE: 07/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/02/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 9
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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Document Has Been Signed on 07/02/2025 04:50 PM - It Cannot Be Edited


Created By: Quoc Huynh On 07/02/2025 at 03:44 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: VALLEY VILLAGE SENIOR LIVING, INC.
FACILITY NUMBER: 197610051

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/02/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(c)(3)
Incidental Medical and Dental Care Services
(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (3) A record of each dose is maintained in the resident's record. The record shall include the date and time the PRN medication was taken, the dosage taken, and the resident's response.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above in 1 out of 6 residents did not have their PRN medications recorded when they were administered which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/03/2025
Plan of Correction
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The Licensee will discuss proper medication documentation with Staff and send CCLD a Statement of Understanding with Staff and Licensee signatures by POC due date.
Type A
Section Cited
CCR
87465(e)
Incidental Medical and Dental Care Services
(e) For every prescription and nonprescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician on a prescription blank, maintained in the resident's file, and a label on the medication. Both the physician's order and the label shall contain at least all of the following information.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above in 1 out of 6 residents did not have a PRN Authorization Letter and 1 resident had 1 out of 2 PRN Medications listed on their Authorization Letter which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/03/2025
Plan of Correction
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The Licensee will obtain updated PRN Authorization Letters for 2 residents and send CCLD proof by 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.
Kristin Heffernan
NAME OF LICENSING PROGRAM MANAGER:
TELEPHONE: (818) 593-4493
Quoc Huynh
NAME OF LICENSING PROGRAM ANALYST:
TELEPHONE: (323) 313-4746
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/02/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/02/2025


LIC809 (FAS) - (06/04)
Page: 3 of 9
Document Has Been Signed on 07/02/2025 04:50 PM - It Cannot Be Edited


Created By: Quoc Huynh On 07/02/2025 at 03:44 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: VALLEY VILLAGE SENIOR LIVING, INC.
FACILITY NUMBER: 197610051

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/02/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87208(a)
Plan of Operation
(a) The licensee shall have and maintain a current, written definitive plan of operation for the facility. The licensee shall operate the facility in accordance with the terms specified in the plan of operation and may be cited for not doing so pursuant to Health and Safety Code section 1569.49. The plan and related materials shall be on file in the facility and shall be submitted to the licensing agency with the license application. Any significant changes in the plan of operation which would affect the services to residents shall be submitted to the licensing agency for approval. The plan and related materials shall contain the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above in that the facility did not have a Plan of Operation on file and was not updated to outline the use of exterior and common area cameras which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/03/2025
Plan of Correction
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The Licensee will send CCLD an updated Plan of Operation and maintain a copy on file at the facility by the POC due date.
Type B
Section Cited
CCR
87457(c)
Pre-Admission Appraisal
(c) Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of their individual service needs in comparison with the admission criteria specified in Section 87455, Acceptance and Retention Limitations.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above in 4 out of 6 residents did not have a Pre-Placement Appraisal which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/11/2025
Plan of Correction
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The Licensee will evaluate the 4 residents with their families and complete an Appraisal, and maintain it annually. The Licensee will send CCLD the completed Appraisals by 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.
Kristin Heffernan
NAME OF LICENSING PROGRAM MANAGER:
TELEPHONE: (818) 593-4493
Quoc Huynh
NAME OF LICENSING PROGRAM ANALYST:
TELEPHONE: (323) 313-4746
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/02/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/02/2025


LIC809 (FAS) - (06/04)
Page: 4 of 9
Document Has Been Signed on 07/02/2025 04:50 PM - It Cannot Be Edited


Created By: Quoc Huynh On 07/02/2025 at 03:44 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: VALLEY VILLAGE SENIOR LIVING, INC.
FACILITY NUMBER: 197610051

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/02/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87458(a)
Medical Assessment
(a) Prior to a person's acceptance as a resident, the licensee shall obtain documentation of a medical assessment, signed by a licensed medical professional acting within the scope of their practice and made within the last year, to be kept in the resident's record.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above in 1 out of 6 residents did not have a Medical Assessment and TB test which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/11/2025
Plan of Correction
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The Licensee will obtain a Medical Assessment and TB test, and send CCLD the reports 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.
Kristin Heffernan
NAME OF LICENSING PROGRAM MANAGER:
TELEPHONE: (818) 593-4493
Quoc Huynh
NAME OF LICENSING PROGRAM ANALYST:
TELEPHONE: (323) 313-4746
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/02/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/02/2025


LIC809 (FAS) - (06/04)
Page: 5 of 9
Document Has Been Signed on 07/02/2025 04:50 PM - It Cannot Be Edited


Created By: Quoc Huynh On 07/02/2025 at 03:48 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: VALLEY VILLAGE SENIOR LIVING, INC.
FACILITY NUMBER: 197610051

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/02/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(6)
(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 prescription medications for each resident is maintained for at least one year and includes: …

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 5 out of 6 residents did not have a Centrally Stored Destruction and Medication Record (CSDMR) which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/07/2025
Plan of Correction
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The Licesee will obtain CSDMR from the pharmacy, or create their own and send CCLD the records 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.
Kristin Heffernan
NAME OF LICENSING PROGRAM MANAGER:
TELEPHONE: (818) 593-4493
Quoc Huynh
NAME OF LICENSING PROGRAM ANALYST:
TELEPHONE: (323) 313-4746
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/02/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/02/2025


LIC809 (FAS) - (06/04)
Page: 9 of 9
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: VALLEY VILLAGE SENIOR LIVING, INC.
FACILITY NUMBER: 197610051
VISIT DATE: 07/02/2025
NARRATIVE
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COMMON AREAS: At the time of the visit, the living room and dining room furniture was observed to be in good condition. The living room had an office area which contained locked file cabinets and a mini fridge that contained medications. LPA observed night lights throughout the facility. The facility maintained a comfortable temperature throughout the visit. Grab bars were provided in the hallway for residents’ use as needed. Also located in the hallway was a laundry closet that was observed to be operational. Locked hallway cabinets contained detergent and general cleaning supplies.

BEDROOMS/RESTROOMS: There were three (3) total bedrooms, each with dual occupancy. Bedroom #1 had a direct exit to the outside and is cleared for one (1) bedridden resident. Bedrooms were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. Extra linens were stored in the hallway cabinets. There were two (2) total restrooms in the facility: one (1) shared common restroom and one (1) private restroom located in Bedroom #3. Restrooms were clean and sanitary and in operating condition with grab bars and non-slip surfaces. All restrooms were sufficiently stocked with soap, paper products, and displayed hand washing signs. Both restrooms had locked cabinets under the sink that stored extra towels or cleaning supplies. Hot water was tested and measured between 115.2 degrees F and 119.8 degrees F.

OUTDOOR AREA: LPA observed a grill, and one (1) patio area equipped with furniture for residents and visitors to use. There is one (1) front door gate and driveway gate used for emergency exits and it is remote and manually operated. No bodies of water noted, and exits are free of obstructions. LPA observed one (1) shed that contained general storage and outdoor equipment that remained locked.

Report Continued on LIC 809-C
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 593-4493
LICENSING EVALUATOR NAME: Quoc HuynhTELEPHONE: (323) 313-4746
LICENSING EVALUATOR SIGNATURE:

DATE: 07/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2025
LIC809 (FAS) - (06/04)
Page: 6 of 9
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: VALLEY VILLAGE SENIOR LIVING, INC.
FACILITY NUMBER: 197610051
VISIT DATE: 07/02/2025
NARRATIVE
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RECORDS: Record review began at 10:58AM. Resident records were reviewed for, but not limited to care plans, physician's report, admissions agreement, and consent forms. LPA observed four (4) out of six (6) residents did not have an Appraisal/Needs and Services Plan on file. The Licensee stated the Appraisals are not required due to the verbiage of the documents, to which the LPA and Licensee had a discussion on the regulations and reviewed current forms. One (1) out of six (6) residents did not have a Physician’s Report or TB test. The Licensee stated they will obtain the resident’s Physician Report from their previous nursing facility. The LPA discussed with the Licensee the use of common area cameras and advised that they update residents’ Admission Agreements with an Addendum stating the use and knowledge of cameras. LPA advised the Licensee to update their Plan of Operation as well regarding the use of cameras. Personnel records were reviewed for, but not limited to health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All files were in order.

MEDICATIONS: Medication review began at 2:37PM. Medications were centrally stored and kept inaccessible in cabinets located near the dining room and hallway. Medications were observed for three (3) residents. Medications are labeled and checked for expiration dates. LPA observed Resident #1 (R1) was prescribed two (2) PRN Medications (Senna 8.6MG and Quetiapine 50MG) and it was not documented when Staff administered them to R1. Additionally, R1’s PRN Authorization Letter authorized the administration of Quetiapine 50MG, but did not list Senna 8.6MG. The Licensee obtained an updated PRN Letter before the conclusion of the visit. The Licensee stated that the facility is in the process of working with their Pharmacy to obtain updated Centrally Stored Destruction and Medication Records (CSDMR) and that four (4) out of six (6) residents did not have a CSDMR.

Report Continued on LIC 809-C
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 593-4493
LICENSING EVALUATOR NAME: Quoc HuynhTELEPHONE: (323) 313-4746
LICENSING EVALUATOR SIGNATURE:

DATE: 07/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2025
LIC809 (FAS) - (06/04)
Page: 7 of 9
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: VALLEY VILLAGE SENIOR LIVING, INC.
FACILITY NUMBER: 197610051
VISIT DATE: 07/02/2025
NARRATIVE
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The review of Resident #2 (R2) revealed that nine (9) out of twelve (12) of their medications were not documented on their CSDMR. Additionally, R2 did not have a PRN Authorization Letter and the Licensee stated they would obtain it.

INFECTION CONTROL/EMERGENCY DISASTER PLAN: During today's visit, the LPA reviewed the facility's infection control plan and emergency disaster plan. Both documents were observed to be complete and reviewed annually as required. Emergency disaster drills are conducted quarterly, with the last documented drill on 05/14/2025. Smoke and Carbon Monoxide alarms were tested at 3:55PM and were operational.

Pursuant to Title 22 CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D).

Exit interview conducted. A copy of today's report and appeal rights were reviewed and provided.
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 593-4493
LICENSING EVALUATOR NAME: Quoc HuynhTELEPHONE: (323) 313-4746
LICENSING EVALUATOR SIGNATURE:

DATE: 07/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2025
LIC809 (FAS) - (06/04)
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