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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610233
Report Date: 01/05/2023
Date Signed: 01/05/2023 02:09:12 PM


Document Has Been Signed on 01/05/2023 02:09 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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364



FACILITY NAME:OASIS SENIOR LIVINGFACILITY NUMBER:
197610233
ADMINISTRATOR:KHAMBEKYAN, SANDYFACILITY TYPE:
740
ADDRESS:7001 GARDEN GROVE AVENUETELEPHONE:
(310) 666-2392
CITY:RESEDASTATE: CAZIP CODE:
91335
CAPACITY:6CENSUS: 4DATE:
01/05/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Khatchik DanielianTIME COMPLETED:
02:19 PM
NARRATIVE
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At 1:45 p.m. on 01/05/2023, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced case management visit due to a facility deficiency. LPA met with the Administrator and disclosed the reason for the visit.

On 01/04/2023 LPA Reed was notified that Administrator Khatchik Danielan’s exemption transfer was not signed by licensee Davit Hakobyan. Therefore the facility is currently operating without a certified administrator. Khatchik stated he would notify the licensee of the required actions.

Exit interview conducted. Copy of report provided. Appeal rights discussed. Deficiency issued on LIC 809-D page.

SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Nicholas ReedTELEPHONE: (818) 669-8178
LICENSING EVALUATOR SIGNATURE:
DATE: 01/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/05/2023
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 2


Document Has Been Signed on 01/05/2023 02:09 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364


FACILITY NAME: OASIS SENIOR LIVING
FACILITY NUMBER: 197610233

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/05/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/06/2023
Section Cited

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87411 Personnel Requirements - General (g) Prior to employment or initial presence in the facility, all employees... shall: (3) Request and be approved for a transfer of a criminal record exemption
This requirement is not met as evidenced by:
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Licensee will sign the administrator's exemption transfer form and send to LPA before close of business on 01/06/2023
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Based on file review and interviews, the licensee did not comply with the section cited in 1 out of 1 administrators which poses an immediate Health, Safety, or Personal Rights risk to residents 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.
SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Nicholas ReedTELEPHONE: (818) 669-8178
LICENSING EVALUATOR SIGNATURE:
DATE: 01/05/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/05/2023
LIC809 (FAS) - (06/04)
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