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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610556
Report Date: 06/09/2025
Date Signed: 06/09/2025 04:41:18 PM

Document Has Been Signed on 06/09/2025 04:41 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:INGOMAR ASSISTED LIVINGFACILITY NUMBER:
197610556
ADMINISTRATOR/
DIRECTOR:		VAHAGN PETROSYANFACILITY TYPE:
740
ADDRESS:19000 INGOMAR STREETTELEPHONE:
(818) 403-1803
CITY:RESEDASTATE: CAZIP CODE:
91335
CAPACITY: 6CENSUS: 3DATE:
06/09/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:30 PM
MET WITH:Nazar Yegeyan Administrator DesigneeTIME VISIT/
INSPECTION COMPLETED:
04:50 PM
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At 1:30 PM, Licensing Program Analyst (LPA) Huma Rahimi, conducted an unannounced annual inspection at the facility mentioned above. LPA met with the staff Dinara Kundakpayeva and the staff contacted the Administrator Designee Nazar Yegeyan. LPA explained the reason for the visit. Physical tour was conducted with the Administrator Designee and LPA observed the following:

KITCHEN: The facility has a kitchen area that is equipped with a refrigerator, microwave oven and sink. LPA observed enough supplies of staple non-perishable for minimum 1 week and perishable for 2 days at the facility. Knives and sharps were observed to be locked in a kitchen drawer and inaccessible. LPA observed staff medication in one of the kitchen drawer accessible to residents in care. LPA also observed insect repellent spray accessible to residents in care.

MEDICATION: LPA observed that the medication and facility staff/resident files are locked in a cabinet located in the living room. During the medication review, LPA did not observe ay discrepancies.

BEDROOMS: There are six (6) bedrooms designated for residents’ private use. All bedrooms are furnished and well equipped with beds, night-stand, chair, dresser, bedding, and extra linen. Rooms were observed to have sufficient lighting and closet space. Auditory alarms were tested and observed to be operational at 1:45 PM. Facility has an awake staff.

Continue on LIC809-C

NAME OF LICENSING PROGRAM MANAGER: Nichelle Gillyard
NAME OF LICENSING PROGRAM ANALYST: Huma Rahimi
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 06/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/09/2025
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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: INGOMAR ASSISTED LIVING
FACILITY NUMBER: 197610556
VISIT DATE: 06/09/2025
NARRATIVE
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BATHROOMS: The facility has six (6) bathrooms, bathrooms #3 and #4 are designated for staff and residents’ family members use. All bathrooms were observed to have the proper fixtures, grab bars, and non-skid mats. The hot water delivered in the bathrooms measured at 1:50 PM to be at 114.4°F degrees. In one of the resident's bathrooms LPA observed comet cleaning powder with bleach in the window shelf being unlocked and accessible to residents in care.

SMOKE DETECTORS/CARBON MONOXIDE. The smoke detectors and carbon monoxide are hard wired, inter-connected and were located throughout the facility. At 2:00 PM they were tested and observed to be operational. The facility has one (1) new fire extinguisher that was purchased on 03/25/2025. The fire extinguisher is located in the kitchen area.

COMMON AREAS: The facility maintains a comfortable temperature at 75°F. The living room and dining appeared clean and were properly furnished. No obstructions and or tripping hazards throughout the facility. LPA observed two supplements in a drawer in the living room.

Laundry: LPA observed laundry room located in a closet in the hallway by the living room with latches on the top of the doors which was easily accessible to residents in care. Inside the laundry LPA observed that laundry detergents and bleach are accessible to residents in care. LPA observed an additional storage area for laundry supplies and other chemicals which was observed locked and inaccessible to residents in care.

SURROUNDING GROUNDS: In the back of the facility has sufficient yard space. LPA observed appropriate outdoor furniture, with covered shaded area for residents. The backyard is fenced. There are no bodies of water.

GARAGE: The garage is currently being used for storage and additional supplies for residents. LPA observed the garage locked and not accessible to residents in care.

Between 2:30 PM to 3:30 PM, LPA reviewed records of three (3) residents and two (2) staff. All three (3) out of three (3) residents did not have admission agreement on file. Staff records appeared to be complete and updated.



Administrative: LPA collected Certificate of Liability Insurance, and LIC500.

Deficiencies issued during today’s visit. Appeal rights explained. Exit interview conducted and copy of this report signed and delivered.

NAME OF LICENSING PROGRAM MANAGER: Nichelle Gillyard
NAME OF LICENSING PROGRAM ANALYST: Huma Rahimi
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2025
LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 06/09/2025 04:41 PM - It Cannot Be Edited


Created By: Huma Rahimi On 06/09/2025 at 04:01 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
, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: INGOMAR ASSISTED LIVING
FACILITY NUMBER: 197610556

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/09/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87507(c)
Admission Agreements
(c) Admission agreements shall be signed and dated, acknowledging the contents of the document, by the resident or the resident's representative, if any, and the licensee or the licensee's designated representative no later than seven days following admission. Attachments to the agreement may be utilized as long as they are also signed and dated as prescribed above.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review the licensee did not comply with the section cited above in three (3) out of three (3) residents admission agreement not on file poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/16/2025
Plan of Correction
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Administrator Administrator agreed to submit all three (3) out of three (3) admission agreement copies to LPA by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
Nichelle Gillyard
NAME OF LICENSING PROGRAM MANAGER:
Huma Rahimi
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/09/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/09/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/09/2025 04:41 PM - It Cannot Be Edited


Created By: Huma Rahimi On 06/09/2025 at 04:04 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
, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: INGOMAR ASSISTED LIVING
FACILITY NUMBER: 197610556

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/09/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87705(f)(2)
(f) The following shall be stored inaccessible to residents with dementia: (f) The following shall be stored inaccessible to residents with dementia: (f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above by having staff medication in kitchen drawer and in a drawer by the medication cabinet in the living room. The licensee also had cleaning solutions in the laundry closet and resident's bathroom accessible to residents in care which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/16/2025
Plan of Correction
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The Administrator Designee locked medication and removed the cleaning solutions from the laundry closet and the bathroom. Administrator Designee agreed to also train staff and submit proof to LPA by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
Nichelle Gillyard
NAME OF LICENSING PROGRAM MANAGER:
Huma Rahimi
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/09/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/09/2025


LIC809 (FAS) - (06/04)
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