197610222-1-28-2026-31-AS-MCAA-DQRUZ8-20260128150106

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610222
Report Date: 01/28/2026
Date Signed: 01/28/2026 03:01:15 PM

Document Has Been Signed on 01/28/2026 03:01 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:	KINGSBURY STREET HOME, INC.		FACILITY NUMBER:	197610222
ADMINISTRATOR/ DIRECTOR:	SARGSIAN, HARUT		FACILITY TYPE:	740
ADDRESS:	16457 KINGSBURY STREET		TELEPHONE:	(818) 519-8080
CITY:	GRANADA HILLS	STATE: CA	ZIP CODE:	91344
CAPACITY: 6		CENSUS: 6	DATE:	01/28/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	11:18 AM
MET WITH:	Gayane Dzhagaryan, Haykuhi Dovlatyan		TIME VISIT/ INSPECTION COMPLETED:	03:00 PM

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	Licensing Program Analyst (LPA) Michael Cava conducted an Annual Required visit and inspection of the facility. LPA met with the staff Haykuhi Dovlatyan, and explained to them the purpose of the visit. The administrator, Gayane Dzhagaryan,, was notified and came to the facility shortly after. At approximately 11:30am, LPA took a tour of the physical plant. Required postings were observed in the entry area. The smoke alarms and carbon monoxide detectors are dual and interconnected. There is a brand new fire extinguisher located in the kitchen. It was purchased on January 28, 2026. Kitchen: The kitchen appliances and fixtures were functional. LPA found a sufficient amount of perishable and non-perishable food properly sealed and stored. Knives were stored in a locked drawer in the kitchen. No cleaning supplies observed out in the open, or accessible to the residents. Bedrooms: There were six (6) bedrooms designated for residents' use. All six bedrooms are for private use. All six bedrooms are properly furnished with appropriate beddings and linens with sufficient lighting. Bathrooms: There are three (3) bathrooms designated for residents' use. All bathrooms were properly supplied and had functional fixtures. Hot water temperature was measured between 115 to 117 degrees Fahrenheit. Bathrooms were clear of any cleaning supplies and toxins. Common Areas: These included the living room and dining area. The living room is furnished with sufficient seating of two couches, a table and television. There is a bookshelf stocked with books and board games.

NAME OF LICENSING PROGRAM MANAGER: Naira Margaryan
NAME OF LICENSING PROGRAM ANALYST: Michael Cava
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 01/28/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/28/2026

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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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: KINGSBURY STREET HOME, INC.	FACILITY NUMBER: 197610222
	VISIT DATE: 01/28/2026

NARRATIVE

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The fireplace is non-functional It is properly screened with a chain screen. The dining room table is large enough to seat six (6) residents. LPA observed floors to be clean and furniture is in good repair. Hallways and passageways were clear of obstruction.

Garage: The garage is attached to the home. Garage is used to store extra canned foods and emergency food and water. No resident access. Garage requires combination to enter.

Laundry: Laundry area is located in between the kitchen and garage entrance. Detergents and cleaning supplies are maintained in the laundry area, which is kept locked and requires a combination to enter.

Surrounding Grounds: Entry/exits were free of obstruction. There is furniture in the backyard appropriate for outdoor use. The outdoor area is large enough to hold outdoor activities and is observed free of hazards.

Staff/office: There is a staff office located at the corner of the living room area where staff and resident files are kept.

Resident Files: LPA conducted a file review of resident records to insure compliance of licensing forms.

Staff Files: LPA conducted a file review of staff records to insure forms and training are up to date and compliance with licensing forms.

Medications: Medications are stored in a locked in a closet near the living room. Medications and medication records were reviewed for appropriate storage and proper documentation.

Pursuant to Title 22 Division 6 of the CA Code of Regulations, there were no deficiencies observed during the visit. Exit Interview Conducted and A Copy of the Report Issued.

NAME OF LICENSING PROGRAM MANAGER: Naira Margaryan
NAME OF LICENSING PROGRAM ANALYST: Michael Cava
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 01/28/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/28/2026

LIC809 (FAS) - (06/04)

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