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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610269
Report Date: 01/28/2025
Date Signed: 01/29/2025 02:21:11 AM

Document Has Been Signed on 01/29/2025 02:21 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.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:HOUSE OF HOPE ASSISTED LIVING, INCFACILITY NUMBER:
197610269
ADMINISTRATOR/
DIRECTOR:		ALABERKYAN, GAYANEFACILITY TYPE:
740
ADDRESS:9617 STANWIN AVENUETELEPHONE:
(818) 302-6344
CITY:ARLETASTATE: CAZIP CODE:
91331
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 3DATE:
01/28/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:45 AM
MET WITH:Shake Sargsyan, CaregiverTIME VISIT/
INSPECTION COMPLETED:
04:30 PM
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On 1/28/2025, Licensing Program Analyst (LPA) Leizl de la Cerra conducted an unannounced annual inspection. LPA was greeted by caregiver and disclosed the reason of the visit. Administrator was contacted. Administrator will not be available to meet LPA.

There are currently three (3) residents who reside at this facility. This facility is approved for six (6) non-ambulatory of which one (1) may be bedridden. Approved hospice waiver for six (06) residents. At approximately 11:30am, LPA toured the facility with staff member and observed the following.

LPA observed dual smoke/carbon monoxide detectors that are hard wired and interconnected. Smoke detector was tested @1:15pm and was observed to function properly. The fire extinguisher is located in the kitchen, appeared to be fully charged and was purchased on July 16, 2024.



KITCHEN: The facility has a Kitchen area that is equipped with a refrigerator, microwave oven and sink. There is also a mini refrigerator, that was observed to be locked, where insulin is being stored. There is an adequate supply of perishable and nonperishable food and dining ware to accommodate a maximum capacity of six (6). An emergency supply of water was also observed in the kitchen. Sharps and knives were observed locked in a kitchen drawer.

BEDROOMS: There are three (3) bedrooms designated for resident use. Bedroom #1 is currently occupied by two (2) residents, and bedroom #2 is occupied by one (1) resident. Bedroom #3 is vacant. All three rooms were furnished with beds, night stand, chairs, dresser, bedding and linen. All three bedrooms have sufficient lighting and closet space.

BATHROOMS: The facility has two (2) bathrooms. LPA observed the bathrooms to have the proper fixtures, grab bars, and non-skid mats. The hot water delivered in the bathrooms measured at 115.2 degrees. No cleaning supplies were observed accessible in the bathroom at this time.
Naira MargaryanTELEPHONE: (818) 596-4368
Leizl De La CerraTELEPHONE: (818) 454-0632
DATE: 01/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/28/2025
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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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: HOUSE OF HOPE ASSISTED LIVING, INC
FACILITY NUMBER: 197610269
VISIT DATE: 01/28/2025
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COMMON AREAS: Facility has one room designated for the living room/activity area. It was equipped with living room furniture, a television, and a coffee table. There is no fireplace. Dining area is located in the kitchen. LPA observed all the furniture in common areas to be in good repair.

LAUNDRY ROOM: The laundry room is located in the garage. Cleaning supplies were stored away and inaccessible to the residents.

MEDICATIONS: Medications are stored locked in one of the kitchen cabinet.

SURROUNDING GROUNDS: The driveway, passageways and entrance to the home was clear of obstruction. The backyard of the facility has a patio and backyard furniture to accommodate the residents. There is a swimming pool that is fenced with a gate that will be kept locked at all times. The fence installed to keep residents out of the swimming pool area is approximately 5 feet high throughout the parameters. A key is required to unlock the padlock to gain entry to the swimming pool as it is kept locked at all times. Adjacent to the swimming pool was another building, which is used for storage. LPA inspected this building and observed used wheelchairs and beds.

Facility Records: At 2:30PM LPA conducted review of resident files and staff records.
LPA reviewed three (3) out three (3) resident files and two (2) staff records were reviewed to ensure compliance. During staff records review LPA observed staff (S1) who was present at the facility giving care to residents, did not have a staff file. S1 is not associated with the facility. LPA observed Administrator's certificated has expired.

Pursuant to Title 22 CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D):
Exit Interview Conducted and a copy of the report was issued.
SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Leizl De La CerraTELEPHONE: (818) 454-0632
LICENSING EVALUATOR SIGNATURE:

DATE: 01/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/28/2025
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 01/29/2025 02:21 AM - It Cannot Be Edited


Created By: Leizl De La Cerra On 01/28/2025 at 03:09 PM
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: HOUSE OF HOPE ASSISTED LIVING, INC
FACILITY NUMBER: 197610269

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/28/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(a)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observations and interviews, the licensee did not ensure that a staff file was completed and maintained at the facility for S1, which poses an immediate health, safety, or personal rights risk to persons in care.
POC Due Date: 02/04/2025
Plan of Correction
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Administrator will provide a copy of the completed staff file for S1 by POC date.
Type B
Section Cited
CCR
87355(e)(3)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 87355(c) or

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview, record review, and observation, the licensee did not comply with the section cited above in staff S1 not being associated to the facility which poses an immediate health, safety, or personal rights risk to persons in care.
POC Due Date: 01/31/2025
Plan of Correction
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The licensee will associate Staff (S1) to the facility prior to their returning to work and submit proof to LPA by the POC due date.
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:Naira Margaryan
TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME:Leizl De La Cerra
TELEPHONE: (818) 454-0632
LICENSING EVALUATOR SIGNATURE:
DATE: 01/28/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/28/2025


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 01/29/2025 02:21 AM - It Cannot Be Edited


Created By: Leizl De La Cerra On 01/28/2025 at 03:14 PM
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: HOUSE OF HOPE ASSISTED LIVING, INC
FACILITY NUMBER: 197610269

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/28/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(d)
Personnel Records
(d) The licensee shall maintain documentation that an administrator has met the certification requirements specified in Section 87406, Administrator Certification Requirements or the recertification requirements in Section 87407, Administrator Recertification Requirements.

This requirement is not met as evidenced by:
Deficient Practice Statement
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This requirement is not met by evidence by: Based on record review, the licensee did not comply with the section cited above in 1 out of 1 staff Administrator Certification expired 9/13/24, which poses an immediate health, safety, or personal rights risk to persons in care.
POC Due Date: 02/04/2025
Plan of Correction
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Administrator will submit the required document to Sacramento and pay the necessary fees to renew certification.
A copy of new administrator certification is due to licensing and provice a copy to LPA by POC date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Naira Margaryan
TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME:Leizl De La Cerra
TELEPHONE: (818) 454-0632
LICENSING EVALUATOR SIGNATURE:
DATE: 01/28/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/28/2025


LIC809 (FAS) - (06/04)
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