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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610379
Report Date: 08/28/2026
Date Signed: 08/28/2026 02:47:03 PM

Document Has Been Signed on 08/28/2026 02:47 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
Lookup Error,
, CA
FACILITY NAME:MY HOME FACILITYFACILITY NUMBER:
197610379
ADMINISTRATOR/
DIRECTOR:		HASMIK NSHANYANFACILITY TYPE:
740
ADDRESS:19837 SEPTO STREETTELEPHONE:
(830) 505-5505
CITY:CHATSWORTHSTATE: CAZIP CODE:
91311
CAPACITY: 6CENSUS: 4DATE:
08/28/2026
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Hasmik Nshanyan - AdministratorTIME VISIT/
INSPECTION COMPLETED:
03:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced required- 1 year visit. LPA met with Lyudmila Tavmasyan, Care staff and explained the purpose of the visit. The administrator Hasmik Nshanyan was called on the phone to inform of the visit and arrived at 11:00am, to assist LPA. The facility is approved to serve residents age range 60 and over, approved for capacity of (6) residents of which (1) may be bedridden. Bedroom #1 cleared for bedridden and approved hospice waiver for (6) hospice residents. Compliance and Regulatory Enforcement (CARE) tool was not utilized during the visit as it is not available for the annual/random type of visit.

The facility has submitted the Infection Control Plan and was last reviewed/updated by the administrator on May 1, 2026. Facility has a valid Liability Insurance, expires on July 12, 2027. Fire drill was last conducted on 07/15/2026. The facility is a single story home consists of (5) resident bedrooms, (2 1/2) bathrooms, kitchen, dining room, living room with covered fireplace, laundry area, attached garage, backyard with gated swimming pool and covered patio. Resident bedrooms were toured and each bedroom has a smoke detector, bed, linen, dresser, light, chair and sufficient closet space. Smoke alarms and carbon monoxide were tested and operable. Knives, sharps are locked in the kitchen drawer and inaccessible to residents. Cleaning solutions and disinfectants are stored under the kitchen sink cabinet, locked and inaccessible to residents. In the attached garage, LPA observed a gallon of bleach and other cleaning supplies stored next to food items such as oatmeal and boxes of cereals. At 10:46am, hot water temperature was measured, at 115.3 deg F in bathroom #1 and 116.2 deg F in bathroom #2 which is within the Title 22 regulations. Exit doors are free of any obstruction. Backyard was inspected and it has a covered sitting area and a gated swimming pool. Fire extinguisher was observed mounted on the wall next to the kitchen, purchased on 11/06/2024. Administrator purchased a new fire extinguisher during the visit. Fire drill was last conducted on 01/17/2026. *****Refer to LIC 809C for the continuation of this report. *****

David Sicairos
Bennette Pena
DATE: 08/28/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/28/2026
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 4
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
Lookup Error,
, CA
FACILITY NAME: MY HOME FACILITY
FACILITY NUMBER: 197610379
VISIT DATE: 08/28/2026
NARRATIVE
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A total of (6) staff members including the Administrator provide care and supervision to the residents. There is a night staff person awake and on duty.Staff employed are over the age of 18, have training and associated to the facility. Administrator's certificate is valid and expires on 09/03/2026. LPA reviewed (3) staff files including the administrator. Proof of staff training and health clearance are current. Resident personal rights are posted. Facility provides internet service and phone to the residents. LPA reviewed (4) resident files. Resident files are maintained in the facility. Admission Agreement, Physician's Report (including TB and Ambulatory Status), Consent for Medical Treatment, Resident Personal Property and Residents Personal Rights observed. There is sufficient space to accommodate both indoor and outdoor activities. There are sufficient food supplies of 2-day perishable and 7-day supplies of non-perishable items. LPA observed the food stored in covered plastic containers in the refrigerator are not labeled and a gallon of milk expired (2) days ago, Aug. 26, 2026. LPA also observed a bottle of dietary supplement/vitamins (Airborne gummies for adults) stored with canned goods and other food supplies. There are no residents with special diets residing at this facility. LPA reviewed residents' medications. The medications are centrally stored and in their original containers. All medications are labeled and are maintained in compliance with label instructions. Medications are administered as prescribed by the Physician. Emergency and Disaster Plan is in place, was reviewed and updated on 11/20/2025. Administrator updated the temporary shelter location/information during the visit. There are (0) hospice and (0) bedridden residents. There are no residents with prohibited health conditions.

Deficiency cited and Technical advisories issued. Exit interview and a copy of this report was provided to Hasmik Nshanyan, Administrator.
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Bennette Pena
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/28/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2026
LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 08/28/2026 02:47 PM - It Cannot Be Edited


Created By: Bennette Pena On 08/28/2026 at 02:10 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
,
, CA

FACILITY NAME: MY HOME FACILITY
FACILITY NUMBER: 197610379

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/28/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/04/2026
Section Cited
HSC
1569.695(c)

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1569.695 Emergency Plans..(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill.... Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
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The administrator will ensure that emergency drill is conducted at least quarterly for each shift. Administrator will submit signed self certification that she read, reviewed & understood HSC1569.695 along with an in-service training emergency drill log.
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Based on record review, the facility conducted the last fire drill on 01/17/2026 but should be conducted at least quarterly and fire drill logs as required. which poses/posed a potential health, safety or personal rights risk to persons in care.
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Administrator agreed to submit all the required proof of corrections to LPA/CCLD by POC due date.

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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.
David Sicairos
NAME OF LICENSING PROGRAM MANAGER:
Bennette Pena
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/28/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/28/2026


LIC809 (FAS) - (06/04)
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