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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610491
Report Date: 07/30/2026
Date Signed: 07/30/2026 01:55:31 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 07/30/2026 01:55 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: 6DATE:
07/30/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:15 AM
MET WITH:Gayane Vardanyan-House ManagerTIME VISIT/
INSPECTION COMPLETED:
01:45 PM
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Licensing Program Analyst (LPA) Nadia Shahbazian conducted an unannounced Required - 1 Year annual inspection visit. Upon arrival at 9:15 am, LPA met with House Manager/Gayane Vardanyan and explained the purpose of the visit. LPA spoke with Administrator/Levon Chalabyan over the telephone, who designated House Manager to sign the report. The Adult Residential Facility (ARF) is licensed for six (6) six non-ambulatory residents ages 18 through 59. Current census is four (4) ambulatory and two (2) non-ambulatory for total of six (6); all clients receive services through Frank D. Lanterman Regional Center.

LPA toured the facility with staff at 10:20 am and observed the following:



Required postings were observed in the hallway. Facility is equipped with a fire door, leading by a ramp to the hallway exit Exit doors are properly marked with exit signs. The front entry is used for the emergency exit, with an additional exit in the back hallway. The smoke/carbon monoxide detectors are dual and interconnected. At 10:25 am the smoke/carbon monoxide detectors were tested and observed to function properly. There is one (1) fire extinguisher in the kitchen, purchased on 04/07/2026. Facility conducts monthly fire and safety drills. The last earthquake drill was conducted on 07/02/2026 and the last fire drill was conducted on 06/02/2026.

COMMON AREAS: The living room is located upon entry and leads to the dining. Both rooms were furnished with couches, dining table/chairs. Television and the games are located in the living room. Facility has land line telephone, internet and wi-fi access for client's use.

Continued on 809-C

Mary G Flores
Nadia Shahbazian
DATE: 07/30/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/30/2026
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: A PEPPER HOUSE
FACILITY NUMBER: 197610491
VISIT DATE: 07/30/2026
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KITCHEN: All appliances and work surfaces were observed to be clean and sanitary. There is a water filtering system, underneath the sink. Knives were stored in a locked drawer in the kitchen. LPA found a sufficient amount of perishable (2 days) and non-perishable (7 days) food, properly stored in cabinets and refrigerator, marked with purchase or expiration dates.

BEDROOMS/BATHROOMS: There are five (5) bedrooms designated for client use. Bedroom #2 is shared. All bedrooms are furnished with beds, dressers, chairs and required bedding and linens. The bedrooms have sufficient closet space, lighting and covered trash cans. There are two (2) bathrooms for staff and clients' 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 bars and non-skid mats. Water temperature was measured between 113.4-114.2 °Fahrenheit, which is within regulation.

Garage/Surrounding grounds: The attached garage is located at the front and is accessed from the dining room and from the backyard. Staff use street parking; the garage is currently used as storage. There is a refrigerator and emergency foods in the garage. The washer/dryer are in the garage with locked cabinets for laundry/kitchen detergents and chemicals. No bodies of water were observed at the facility. There is a covered patio on the side yard, with furniture appropriate for use of all clients. There is a detached shed/room in the backyard, used as storage, kept locked and inaccessible to residents.

Resident Files: A review of six out of six client records was conducted to ensure compliance of licensing required forms. P&I for all six clients were also counted and compared to receipts and purchase records.

Medication: Medications were stored in a locked hallway cabinet. Medications records for all six clients were reviewed and medications were counted and verified for accuracy of administration. LPA observed two complete first aid kits, along with a first aid manual.

Staff Files: Staff files for five (5) staff were reviewed to ensure all forms and training certificates are current.

LPA reviewed the facility liability insurance which expires on 06/12/2027. Surety Bond in the amount of $10,000 was issued on 02/14/2026. The Infection Control Plan and 12/21 Emergency and Disaster Plan was reviewed. Administrator Certificate Expires on 08/20/2027.



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.

NAME OF LICENSING PROGRAM MANAGER: Mary G Flores
NAME OF LICENSING PROGRAM ANALYST: Nadia Shahbazian
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/30/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/30/2026
LIC809 (FAS) - (06/04)
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