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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610144
Report Date: 06/19/2025
Date Signed: 06/19/2025 11:59:46 AM

Document Has Been Signed on 06/19/2025 11:59 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.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:VICTORIA'S DIGNITY CAREFACILITY NUMBER:
197610144
ADMINISTRATOR/
DIRECTOR:		BERGHOUDIAN, JACK JFACILITY TYPE:
740
ADDRESS:13874 KELOWNA ST.TELEPHONE:
(818) 894-5761
CITY:ARLETASTATE: CAZIP CODE:
91331
CAPACITY: 6CENSUS: 6DATE:
06/19/2025
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Jack BerghoudianTIME VISIT/
INSPECTION COMPLETED:
12:00 PM
NARRATIVE
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At 9:30 a.m. on 06/19/25, Licensing Program Manager (LPM) Naira Margaryan and Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced complaint visit. LPA met with staff and disclosed the reason for the visit.

Today’s case management visit was conducted to ensure the health and safety of facility residents and the facility’s compliance to Title 22 Regulations.

LPM and LPA interviewed staff and residents between 9:40 a.m. and 11:30 a.m. today, conducted a record review of pertinent records, including but not limited to an admission agreement, medical assessment, care plan, and staff and client rosters at 9:45 a.m., and toured the facility inside and out at 11:15 a.m.

Interview with Staff #1 (S1) at approximately 10:45 a.m. revealed that Staff #2 (S2) was a live-in staff. S1 further noted that Resident #1 (R1) was recently admitted. The facility moved Resident #2 (R2) into the staff room when R1 was admitted. Facility tour revealed two beds were set up in the staff room. Record review revealed R1 was admitted to the facility on 06/06/25. A deficiency is issued for a resident sleeping in the staff room. During the facility tour, LPA observed Resident #3 (R3) was residing in Bedroom #2. Record review of R3’s medical assessment revealed they are bedridden. File review of the facility’s fire clearance at 11:15 a.m. today revealed Bedroom #3 was designated for a bedridden resident. Interview with S1 revealed R3 has been residing in Bedroom #2 for over two (02) years. A deficiency is issued for violating the facility’s fire clearance by placing a bedridden resident in a non-ambulatory room which was not designated for bedridden residents. Other deficiencies were discovered during this visit which will be cited at a later date.

Exit interview conducted. Appeal rights discussed. Copy of report provided.

NAME OF LICENSING PROGRAM MANAGER: Naira Margaryan
NAME OF LICENSING PROGRAM ANALYST: Nicholas Reed
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 06/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/19/2025
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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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 06/19/2025 11:59 AM - It Cannot Be Edited


Created By: Nicholas Reed On 06/19/2025 at 11:34 AM
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., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: VICTORIA'S DIGNITY CARE
FACILITY NUMBER: 197610144

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/19/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/20/2025
Section Cited
CCR
87307(a)

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87307 Personal Accommodations and Services (a) Living accommodations... shall be related to the facility's function. The facility shall... provide comfortable living accommodations and privacy for the residents, staff, and others... This requirement was not met as evidenced by:
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Within 24 hours, the administrator designee will provide written statement explaining the plan to correct the deficiency. LPA advised that the plan must be measurable and verificable with photographic evidence of correction.
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Based on interviews, record review, and observations, the licensee did not comply with the section cited above by placing a resident in the staff room which posed an immediate risk to the Health, Safety, or Personal Rights of persons in care.
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Type A
06/20/2025
Section Cited
HSC1569.72(c)

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§1569.72 Residents requiring skilled nursing or intermediate care; bedridden residents (c) Notwithstanding... bedridden persons may be admitted to, and remain in, residential care facilities for the elderly that secure and maintain an appropriate fire clearance. This requirement was not met as evidenced by:
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Administrator to request resident and representative permissions and switch residents in Bedroom #2 with residents in Bedroom #3. LPA advised that information must be measurable and verificable with photographic evidence of correction.
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Based on interviews, record review, and observations, the licensee did not comply with the section cited above by placing a bedridden resident in a room which was not cleared for a bedridden resident which posed an immediate risk to the Health, Safety, or Personal Rights of persons in care.
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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.
Naira Margaryan
NAME OF LICENSING PROGRAM MANAGER:
Nicholas Reed
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/19/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/19/2025


LIC809 (FAS) - (06/04)
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