197610051-8-18-2026-29-AS-KHEN-DXDVBZ-20260828161823

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197610051
Report Date: 08/18/2026
Date Signed: 08/18/2026 02:16:37 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/29/2026 and conducted by Evaluator Quoc Huynh

PUBLIC

COMPLAINT CONTROL NUMBER: 29-AS-20260429152318

FACILITY NAME:	VALLEY VILLAGE SENIOR LIVING, INC.		FACILITY NUMBER:	197610051
ADMINISTRATOR:	AYVAZYAN, SARGIS		FACILITY TYPE:	740
ADDRESS:	5541 VANTAGE AVE.		TELEPHONE:	(818) 301-7551
CITY:	VALLEY VILLAGE	STATE: CA	ZIP CODE:	91607
CAPACITY:	6	CENSUS: 6	DATE:	08/18/2026
		UNANNOUNCED	TIME BEGAN:	10:19 AM
MET WITH:	Sargis Ayvazyan - Administrator		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility did not provide records to resident's responsible party

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Quoc Huynh conducted a subsequent complaint visit to deliver findings for the above allegation. The LPA arrived at 10:19AM and met with Administrator Sargis Ayvazyan. Entrance interview conducted.

On 04/30/2026, LPAs Huynh and Angela Barutyan conducted an initial visit. Between 1:48PM and 3:15PM, the LPAs conducted a physical plant tour, interviewed the Administrator, and reviewed and obtained pertinent documents.

During today’s visit, LPA Huynh conducted a physical plant tour at 10:27AM, and no immediate concerns were observed. The following was then determined:

Report Continued on LIC 9099-C

Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Quoc Huynh
LICENSING EVALUATOR SIGNATURE:	DATE: 08/18/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2026

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 1 of 6

Control Number 29-AS-20260429152318

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 08/18/2026

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
26
27
28
29
30
31
32

Allegation: “Facility did not provide records to resident’s responsible party”

It was reported that the facility Administrator did not provide Resident #1’s (R1) Responsible Person (RP) with R1’s records. Interview with the Administrator indicated that the RP requested medical documents on approximately 04/13/2026 when they removed R1’s belongings and was informed that the facility did not maintain medical records. The RP then requested R1’s file again on 04/29/2026 and the Administrator stated they intended to provide the documents. After the allegation was disclosed during the initial visit conducted on 04/30/2026, the Administrator then proceeded to rescind their statement and stated the RP only requested documents on 04/29/2026.

Interview with the RP on 08/10/2026 revealed that the Administrator only provided them with R1’s admission agreement, despite requesting the file in its entirety including medication lists. The RP reported that the Administrator informed them that the facility does not “have any here.”

During today’s visit, the Administrator confirmed and provided proof that they provided the RP with the Admission Agreement, Urinary Tract Infection (UTI) lab report, and prescribed antibiotic order to treat the UTI on 04/30/2026. The Administrator stated that the RP did not request additional documents and confirmed that the remainder of R1’s file was not provided.

Based on interviews, the preponderance of evidence standard has been met; therefore, the allegation is deemed SUBSTANTIATED at this time.

Pursuant to Title 22 CA Code of Regulations and/or the Health and Safety Code, the following deficiency was cited (Refer to LIC 9099-D).

Exit interview conducted. A copy of the appeal rights and report was reviewed and provided.

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Quoc Huynh
LICENSING EVALUATOR SIGNATURE:	DATE: 08/18/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2026

LIC9099 (FAS) - (06/04)

Page: 2 of 6

Control Number 29-AS-20260429152318

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/18/2026

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 08/28/2026 Section Cited CCR 87468.2(a)(19)	1 2 3 4 5 6 7	(a) In addition to the rights listed in Section 87468.1… (19) To have prompt access to review all of their records and to purchase photocopies of their records. Photocopied records shall be provided within two (2) business days… This requirement was not met as evidenced by:	1 2 3 4 5 6 7	The Licensee will provide R1's Responsible Person with R1's entire file and provide proof to CCLD by POC due date.
	8 9 10 11 12 13 14	Based on interviews the Licensee did not comply with the above cited section in R1’s Responsible Person was not provided all of R1’s records which poses/posed a potential personal rights risk to persons in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Quoc Huynh
LICENSING EVALUATOR SIGNATURE:	DATE: 08/18/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2026

LIC9099 (FAS) - (06/04)

Page: 3 of 6

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/29/2026 and conducted by Evaluator Quoc Huynh

PUBLIC

COMPLAINT CONTROL NUMBER: 29-AS-20260429152318

FACILITY NAME:	VALLEY VILLAGE SENIOR LIVING, INC.		FACILITY NUMBER:	197610051
ADMINISTRATOR:	AYVAZYAN, SARGIS		FACILITY TYPE:	740
ADDRESS:	5541 VANTAGE AVE.		TELEPHONE:	(818) 301-7551
CITY:	VALLEY VILLAGE	STATE:CA	ZIP CODE:	91607
CAPACITY:	6	CENSUS: 6	DATE:	08/18/2026
		UNANNOUNCED	TIME BEGAN:	10:19 AM
MET WITH:	Sargis Ayvazyan - Administrator		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff did not seek medical attention to resident in a timely manner resulting in death of resident

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Quoc Huynh
LICENSING EVALUATOR SIGNATURE:	DATE: 08/18/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2026

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 4 of 6

Control Number 29-AS-20260429152318

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 08/18/2026

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
26
27
28
29
30
31
32

Allegation: “Staff did not seek medical attention to resident in a timely manner resulting in death of resident”

It was reported that Resident #1 (R1) was not provided medical attention in a timely manner, which resulted in their death. R1’s Physician Report dated 07/23/2023 documented diagnoses including dementia, chronic obstructive pulmonary disease (COPD), and generalized weakness. R1 was non-ambulatory, required continuous bed care, assistance with activities of daily living (ADLs), and was noted to receive hospice services due to COPD.

Interview with R1’s Responsible Person (RP) indicated that R1 experienced a significant change in condition between 03/01/2026 and 04/06/2026, including a urinary tract infection (UTI), weight loss due to loss of appetite, and wound care needs. The RP reported that when R1 was admitted to home health services in February 2026, R1 was verbal and eating meals without complications. The RP stated that the Administrator did not notify them of R1’s UTI, loss of appetite, and overall decline until the RP visited the facility on 04/06/2026 and observed R1 to be in need of medical attention. The RP reported they did not contact 911 themselves because they trusted the Administrator to oversee R1’s health.

The Administrator reported that R1 contracted a UTI in March 2026 and was prescribed antibiotics, which reportedly resolved the issue. The Administrator stated that approximately two (2) weeks prior to R1’s hospitalization and death, they notified the RP that R1’s condition was declining and that R1 was not eating. On 04/08/2026, a caregiver informed the Administrator that R1’s oxygen saturation was low. The Administrator stated they contacted the RP for guidance, and the RP confirmed the need for hospital transport.

Report Continued on LIC 9099-C

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Quoc Huynh
LICENSING EVALUATOR SIGNATURE:	DATE: 08/18/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2026

LIC9099 (FAS) - (06/04)

Page: 5 of 6

Control Number 29-AS-20260429152318

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 08/18/2026

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
26
27
28
29
30
31
32

Interview with staff indicated no overall concerns. Staff reported they monitored R1’s vital signs two (2) times a day and noted no issues until 04/08/2026, when R1’s oxygen level and blood pressure were low. Staff stated they notified the Administrator, who arrived at the facility approximately fifteen (15) minutes later, followed by ambulance services approximately five (5) minutes after the Administrator’s arrival. Staff also confirmed R1’s antibiotics for the UTI were administered two (2) times a day for ten (10) days as prescribed.

Home health records documented diagnoses including hypertensive heart disease, COPD, hypotension, depression, and aphasia. On 03/16/2026, R1 was noted to have poor appetite and was only consuming approximately fifty percent (50%) of meals. On 03/23/2026, R1 exhibited symptoms suggestive of a UTI, and on 03/30/2026, an open wound on the coccyx area was documented along with urine testing confirming a UTI. On 04/04/2026, R1 completed the prescribed antibiotics, and UTI symptoms were noted as relieved. On 04/05/2026, R1’s appetite was reported as “fair,” and the Stage II pressure ulcer on the sacral area demonstrated signs of healing. Home health records did not reveal additional complaints or abnormalities observed during visits.

Hospital records showed that on 04/08/2026, R1 was admitted with unspecified cardiac arrest. Critical interventions were required due to a high probability of imminent organ system deterioration. R1 ultimately succumbed to a cardiac arrest while bradycardic, and intubation efforts were unsuccessful. The Los Angeles County Medical Examiner Report confirmed R1’s cause of death as natural, due to sepsis. A secondary cause of death was documented as a kidney infection resulting from a lower UTI and kidney stones. A Medical Examiner Investigator additionally confirmed that R1’s death did not appear negligent and could not have occurred even if R1 received “top notch” medical care.

Based on interviews and record review, although the allegation may have happened or is valid, there is insufficient evidence to prove the alleged violation did or did not occur; therefore, the allegation is deemed UNSUBSTANTIATED at this time.

No deficiency cited. Exit interview conducted. A copy of the report was reviewed and provided.

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Quoc Huynh
LICENSING EVALUATOR SIGNATURE:	DATE: 08/18/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2026

LIC9099 (FAS) - (06/04)

Page: 6 of 6