<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610491
Report Date: 07/17/2025
Date Signed: 07/17/2025 04:13:27 PM

Document Has Been Signed on 07/17/2025 04:13 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:A PEPPER HOUSEFACILITY NUMBER:
197610491
ADMINISTRATOR/
DIRECTOR:		CHALABYAN, LEVONFACILITY TYPE:
735
ADDRESS:2124 N. PEPPER STREETTELEPHONE:
(818) 472-7878
CITY:BURBANKSTATE: CAZIP CODE:
91505
CAPACITY: 6CENSUS: 5DATE:
07/17/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:30 AM
MET WITH:Levon Chalabyan-AdministatorTIME VISIT/
INSPECTION COMPLETED:
04:00 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Nadia Shahbazian conducted an unannounced Required - 1 Year annual inspection visit. Upon arrival at 8:30 am, LPA met with House Manager/Gayane Vardanyan and explained the purpose of the visit. Administrator/Levon Chalabyan arrived at 9:20 am. The program is vendorized through the Frank D. Lanterman Regional Center. The Adult Residential Facility is licensed for six (06) six non-ambulatory residents ages 18 through 59. Current census is four (4) ambulatory and one (1) non-ambulatory resident; all residents were admitted together on 05/30/2025.

LPA toured the facility with the Administrator at 10:40 am and observed the following:



Required postings were observed in the hallway. The front entry is the main exit, with an additional exit in the back of the hallway. Both exits were properly marked with an "exit sign". Facility is equipped with a fire door, leading to the hallway. The physical plant appeared clean, sanitary and with no visible immediate hazards. There is one (1) fire extinguisher in the kitchen, purchased on 06/16/2025. Facility conducts monthly fire and safety drills. The last earthquake drill was conducted on 07/01/2025 and the last fire drill was conducted on 06/01/2025. LPA reviewed the facility liability insurance which expires on 04/14/2026. The dual smoke alarms and carbon monoxide detectors are hardwired and interconnected. At 11:09 am the smoke/carbon monoxide detectors were tested and observed to function properly.

Kitchen: There is a refrigerator, stove, microwave and dishwasher in the kitchen with a breakfast nook with chairs. Knives, cutlery and other sharp kitchen utensils are stored and locked in the kitchen drawer. Food storage and preparation areas are clean and sanitary. LPA found a sufficient amount of perishable food (2 days) and non-perishable food supplies (7 days) in kitchen cabinets and refrigerator. All food supplies were properly dated and stored.

(Continued on 809C)

NAME OF LICENSING PROGRAM MANAGER: Eva Miller
NAME OF LICENSING PROGRAM ANALYST: Nadia Shahbazian
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/17/2025
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)
Page: 2 of 4
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: A PEPPER HOUSE
FACILITY NUMBER: 197610491
VISIT DATE: 07/17/2025
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Common Areas: Include a living room and dining room. The office area is located of one corners of the dining room. Dining room is furnished with a table and ten (10) chairs. The living room is furnished with sofas to accommodate sitting for all the residents and staff. A television set and a book case for activity/gaming areas were observed in the living room.

BEDROOMS: There are five (5) bedrooms designated for client use. Bedroom #1 is currently vacant and bedroom #2 is shared. All bedrooms are furnished with beds, dressers and required bedding and linen. The bedrooms have sufficient closet space, lighting and covered trash cans.

BATHROOMS: There are two (2) bathrooms for staff and residents' use. Both bathrooms were observed to be clean and in good repair and properly supplied with toilet papers, soap and paper towels. LPA observed appropriate grab bar and had non-skid mats. Water temperature was between 116.1 -118.2 °Fahrenheit, which is within regulation.


Garage: The attached garage is located near the dining room and LPA observed a locked door leading to the garage, which is currently being utilized as a supply room. There is a refrigerator, supplied with marked and dated food items. There is a washer/dryer in the garage with a locked cabinet for laundry detergents and chemicals. The Administrator pointed out to LPA that there was a partition across the garage, as a separator, which was removed and the new sketch was already sent to CCL. The removal of the partition, required no construction permits, since it was a free-standing partition.

Surrounding grounds: Entry/exit gates and pathways were free of obstruction. The outdoor area was free of visible immediate hazards. No bodies of water were observed at the facility. There is ample patio space for outdoor activities. There is a covered patio, on the side yard, with furniture appropriate for use of all residents. There is a detached shed, used as storage, in which detergents and other supplies are kept locked and inaccessible to residents.

(Continued on 809-C)5200218902

5

NAME OF LICENSING PROGRAM MANAGER: Eva Miller
NAME OF LICENSING PROGRAM ANALYST: Nadia Shahbazian
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2025
LIC809 (FAS) - (06/04)
Page: 3 of 4
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: A PEPPER HOUSE
FACILITY NUMBER: 197610491
VISIT DATE: 07/17/2025
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Resident Files: A review of five out of five resident records was conducted to ensure compliance of licensing required forms. Medications records for all residents were counted and verified for accuracy of administration based on physician orders. P&I for all five residents were also counted and compared to receipts and purchase records.

Medication: Medications were stored in a locked cabinets in the hallway. LPA observed a complete first aid kit, along with a first aid manual.

Staff Files: Staff files were reviewed to ensure all forms and training certificates are up to date.

Pursuant to Title 22 Division 6 of the CA Code of Regulations, no deficiencies observed during the visit.

Exit Interview Conducted / A Copy of the Report provided to Administrator.

NAME OF LICENSING PROGRAM MANAGER: Eva Miller
NAME OF LICENSING PROGRAM ANALYST: Nadia Shahbazian
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2025
LIC809 (FAS) - (06/04)
Page: 4 of 4