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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610554
Report Date: 10/19/2025
Date Signed: 10/19/2025 01:07:06 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 10/19/2025 01:07 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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:OTRIUM CARE HOMESFACILITY NUMBER:
197610554
ADMINISTRATOR/
DIRECTOR:		SAHAKYAN, DAVIDFACILITY TYPE:
740
ADDRESS:15933 RAYEN STREETTELEPHONE:
(310) 404-3778
CITY:NORTH HILLSSTATE: CAZIP CODE:
91343
CAPACITY: 6CENSUS: 1DATE:
10/19/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Bagrat Davtyn, CaregiverTIME VISIT/
INSPECTION COMPLETED:
01:15 PM
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Licensing Program Analyst (LPA), Tihesha Smith conducted an unannounced Required 1-year inspection at this facility at approximately 9:30 am. LPA was greeted by the staff and disclosed the purpose of the visit. The licensee/administrator was contacted. The designee Bagrat Davtyan arrived at approximately 10:30 am.

LPA conducted a tour of the physical plant to ensure there are no health and safety hazards, and the facility is following Title 22 Regulations.

Common areas, including the living room and the combined kitchen and dining room, were evaluated for their ability to safely meet residents' needs. These spaces were inspected for cleanliness, and furniture was assessed for functionality and condition. All common areas were found to be clean, sanitary, and furnished with seating sufficient to accommodate residents comfortably.

LPA Smith reviewed the food service areas, food storage and supply (perishable and nonperishable foods). The kitchen food supply was observed and sufficient for the one (1) residents currently residing there. Two (2) days of perishable food observed. The freezer is stocked with frozen foods. Resident medications locked in a file cabinet located in the office area next to the kitchen. Sharps are stored and locked under stove cabinet and observed to be locked and inaccessible to resident. There is one (1) fire extinguisher in facility attached to the wall in dining area and observed to be charged. Laundry room is located in separated room at side of kitchen near staff bathroom. The appliances observed to be functional.
NAME OF LICENSING PROGRAM MANAGER: Naira Margaryan
NAME OF LICENSING PROGRAM ANALYST: Tihesha Smith
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 10/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/19/2025
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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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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: OTRIUM CARE HOMES
FACILITY NUMBER: 197610554
VISIT DATE: 10/19/2025
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The facility has a total of four (4) bedrooms and three (3) bathrooms, with two (2) bathrooms designated for residents’ use. The residents’ bedrooms were furnished with at least one chair, nightstand, and sufficient lighting for each resident. The bedrooms had appropriate and adequate bedding and linens such as sheets, pillowcases, and blankets. Linens stored in hall cabinets next to the main bathroom.

The hot water temperature was measured for the main bathroom to ensure it is within the required range for residents’ comfort and safety. The water temperature range was 107.9-degrees Fahrenheit. Bedroom #1 has an ensuite bathroom. The water was not checked due to the bathroom being renovated at the time of visit with workers present at the facility.

Backyard has the following: Covered patio with table chairs. Patio furniture is observed to be in good repair with adequate seating for residents.
Attached Garage but no indoor access: Used for storage
Carbon monoxide and smoke detectors were tested at 12:15 pm and operable at time of visit.

The following items were observed:

Change of ownership/business sold
Ensuite bathroom in bedroom #1 is being renovated at time of visit
Fire door hold open device missing
Main bathroom doorway expanded renovation
No department notification for changes
Main Bathroom walls

Deficiencies will be addressed on a Case Management Visit

Exit Interview Conducted /Copy of the Report Issued.

NAME OF LICENSING PROGRAM MANAGER: Naira Margaryan
NAME OF LICENSING PROGRAM ANALYST: Tihesha Smith
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2025
LIC809 (FAS) - (06/04)
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