197610319-4-21-2026-31-AS-RCOR-DTCQFP-20260421120815

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610319
Report Date: 04/21/2026
Date Signed: 04/21/2026 12:08:24 PM

Document Has Been Signed on 04/21/2026 12:08 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:	BEL AIR GUEST HOME		FACILITY NUMBER:	197610319
ADMINISTRATOR/ DIRECTOR:	SAMUEL, GALINA		FACILITY TYPE:	735
ADDRESS:	1440 N. STANLEY AVENUE		TELEPHONE:	(323) 876-3370
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90046
CAPACITY: 65		CENSUS: 59	DATE:	04/21/2026
TYPE OF VISIT:	Case Management - Other	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:00 AM
MET WITH:	Irma Robles-Assistant Admistrator		TIME VISIT/ INSPECTION COMPLETED:	12:20 PM

NARRATIVE

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At 8:00am, Licensing Program Manager (LPM) Naira Margaryan, and Licensing Program Analyst (LPA) Ray Comer, conducted an unannounced case management visit to the facility for a welfare check, observe if the facility maintained sufficient number of qualified personnel, and verify that facility’s staff schedule was followed. LPM\LPA met with the cook/Assistant Administrator and explained the reason for the visit. The Licensee representatives and Administrators Joseph Samuel and Galina Samuel arrived to the facility at 9:00am. LPM\LPA discussed with the Administrator concerns regarding the observed staffing gaps at the facility.
On 2/26/26, LPA’s Ray Comer and Gary Tan arrived at the facility for observations of night welfare checks and verify staff presence at the facility. During this visit, a copy of the facility’s staff schedule was obtained. On 4/6/26, LPA Comer reviewed the obtained schedule and observed the following:

• Monday thru Friday, no technical “staff” were scheduled to oversee residents from 8am – 6pm.

• On Monday mornings, staff schedule shows the night shift supervisor is off at 8am. However, no

staff are scheduled to supervise facility from 8:00am to 8:30 am.

• On Sundays, staff schedule failed to provide any available staffing from 8:30am – 6pm to provide

resident assistance; only two (2) housekeepers/cooks were shown on schedule at this time.

• On Sundays, staff schedule did not show any caregiver staffing from 8:30am – 6pm; only two (2)

housekeepers/cooks coming were shown on schedule at this time.

• On Tuesdays, No staff are scheduled to oversee clients from 11pm – 8am.

• On Saturdays, schedule did not show presence of resident service staff from 5:30pm -6pm.

[LIC809C] Continued

NAME OF LICENSING PROGRAM MANAGER: Naira Margaryan
NAME OF LICENSING PROGRAM ANALYST: Raymond Comer
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/21/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2026

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: BEL AIR GUEST HOME	FACILITY NUMBER: 197610319
	VISIT DATE: 04/21/2026

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LPA comer spoke with the Administrator via phone, discussed the observed staffing gaps, and communicated that the reviewed schedule is not compliant with Title 22 Personal requirements (87411) and licensee’s (87208) Plan of Operation.
Based on an updated staff scheduled, submitted on 4/6/26 to Community Care Licensing, (CCL) by the facility Administrator, Staff#1 (S1) Office Assistant, and Staff#2 (S2) Activities Director are scheduled to be present at 8:00am.
Upon arrival at 8:02am, Staff#3 (S3) Cook\Assistant Administrator was not present in the office as scheduled. S3 was in the kitchen area fulfilling their main obligations as a facility cook. There were no other staff available in the facility until about 9:00am, when the Administrators arrived. Additionally, it was observed that the updated staff schedule was not posted; instead, the previous staff schedule was posted showing gaps in service provision.
The updated schedule was reviewed with the Administrators to acknowledge inconsistencies between updated schedule and arrival/presence of the staff in the facility. The facility program plan was reviewed, and the Licensee representatives were advised that as per facility program plan approved by the CDSS, in addition to the main personnel, the facility supposed to have additional support staff as necessary to ensure smooth operation of the facility.
Per program plan facility should have the following personnel
1. CAREGIVERS, HOUSEKEEPERS, MAINTENANCE PERSONNEL
2. EMPLOYEE TO PERFORM OFFICE DUTIES
3. FULL-TIME STAFF CONDUCT AND EVALUATE ACTIVITIES.
4. FULL TIME EMPLOYEE RESPONSIBLE FOR THE FOOD SERVICE PROGRAM (COOK)

LPM and LPA advised the Administrator that Currant facility schedule does not identify main duties for each staff. The staff may carry on additional duties as needed. However, the schedule must identify their primary duties.
Licensees/Administrators acknowledge the importance of the presence of qualified staff at the facility, per each shift and agreed to review and update the schedule to ensure appropriate coverage. Licensee/Administrator stated to LPM/LPA that a revised staff schedule will be submitted to CCL on 4/23/26.
Licensee was issued a Technical Advisory at the time of LPM/LPA visit and was informed that further noncompliance of noted issues will result in citations and possible civil penalties.

An exit interview conducted, and a copy of this report issued to the Administrator.

NAME OF LICENSING PROGRAM MANAGER: Naira Margaryan
NAME OF LICENSING PROGRAM ANALYST: Raymond Comer
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/21/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2026

LIC809 (FAS) - (06/04)

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