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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610255
Report Date: 05/07/2025
Date Signed: 05/07/2025 12:59:08 PM

Document Has Been Signed on 05/07/2025 12:59 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:AMAZING SENIOR CARE ON LASSEN, INC.FACILITY NUMBER:
197610255
ADMINISTRATOR/
DIRECTOR:		ALADADYAN, YELENAFACILITY TYPE:
740
ADDRESS:17127 LASSEN STTELEPHONE:
(818) 207-4220
CITY:NORTHRIDGESTATE: CAZIP CODE:
91325
CAPACITY: 6CENSUS: 6DATE:
05/07/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:25 AM
MET WITH:Yelena Aladadyan, AdministratorTIME VISIT/
INSPECTION COMPLETED:
01:05 PM
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On 05/07/25, at 09:25am, Licensing Program Analyst (LPA) Gina Saucedo arrived at the facility to conduct an unannounced, annual visit. LPA was met by caregiver, Zhana Ghambaryan. The administrator Yelena Aladadyan arrived about 15 (fifteen) minutes later. There was also another staff present at the time of visit.

The physical plant was toured inside and out at 10:15 am.

Living/Dining Room Area: LPA observed the living room furniture to be clean and in good repair. The facility maintains a comfortable temperature at 71 degrees Fahrenheit. The fireplace is secured in the living room area covered by a black gate.

Bedrooms: All three (3) bedrooms are shared. The three (3) resident rooms are numbered. Two (2) of the bedrooms have private bathrooms. LPA observed rooms to have bedding sheets, pillowcase, blankets, nightstands, televisions, and sufficient lighting for each of the residents sharing the room.

Bathrooms: All three (3) bathrooms were toured and checked to make sure bathrooms were clean and in good repair. The hot water temperature measured within regulations of 116 degrees Fahrenheit and 117. The showers have non-slip bath mats and grab bars. There is another bathroom on your right hand side of the entrance of the facility.

Medications were kept in a locked cabinet in the bedroom hallway. All medications were properly labeled and inaccessible to residents. There is a complete first aid kit located in the kitchen.

LIC 809C-Continued

NAME OF LICENSING PROGRAM MANAGER: Troy Agard
NAME OF LICENSING PROGRAM ANALYST: Gina Saucedo
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/07/2025
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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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: AMAZING SENIOR CARE ON LASSEN, INC.
FACILITY NUMBER: 197610255
VISIT DATE: 05/07/2025
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Kitchen Area: LPA inspected the kitchen area. The refrigerator was clean and in good operation. Fire extinguisher was observed to be full and expires October 2025. Knives and sharp objects were kept centrally stored and locked in a cabinet located in the kitchen on your left-hand side. LPA observed sufficient supply of seven (7) day non-perishable and perishable foods in the cabinet.

Garage: In addition, there is another refrigerator in the garage stored with extra food. The washer and dryer are also located in the garage. Cleaning supplies/toxins were kept locked in the garage being inaccessible to residents on the top shelf of the washer and dryer.

Outside: LPA toured the outside area. LPA observed a covered shaded area for residents and appropriate outdoor furniture. The facility has no body of water on the premises. There is one (1) gate that is locked leading to the outside area towards the street. There are also ramps provided for wheelchair residents. There is a shed that contains extra wheelchairs and resident property. There is a side door on your left hand side of the entrance of the facility that leads to a living area which is empty. There are no residents and/or staff in that area. LPA was able to tour that area.

Administration: The mitigation and the Infection control were reviewed and are kept in a binder and there was Covid 19 signs on the wall, hygiene sanitation signs, Personal Rights, Visitation Rights, Theft and Loss Policies, Emergency and Disaster Plan, Report of suspected abuse, Rights of Resident Council, Ombudsman and YES sign, surety bond was viewed, and it is up to date-08/10/24-08/10/25.

The staff and the resident files were in a secure/private location in the dining hall area on your left hand side.

The carbon monoxide is interconnected with the smoke detector was tested and it was operable. The facility has a signal system currently there is only one (1) dementia resident.

An exit interview was conducted, no citation(s) were issued, and a copy of this report was given to the administrator.

NAME OF LICENSING PROGRAM MANAGER: Troy Agard
NAME OF LICENSING PROGRAM ANALYST: Gina Saucedo
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/07/2025
LIC809 (FAS) - (06/04)
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