197610567-5-7-2026-31-AS-PKHN-DTUTM4-20260507145031

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610567
Report Date: 05/07/2026
Date Signed: 05/07/2026 02:52:23 PM

Document Has Been Signed on 05/07/2026 02:52 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:	SAINT MARIAM SENIOR CARE		FACILITY NUMBER:	197610567
ADMINISTRATOR/ DIRECTOR:	MARINA ZHIGOYAN		FACILITY TYPE:	740
ADDRESS:	18228 ACRE STREET		TELEPHONE:	(818) 436-4701
CITY:	NORTHRIDGE	STATE: CA	ZIP CODE:	91325
CAPACITY: 6		CENSUS: 4	DATE:	05/07/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:46 AM
MET WITH:	Hayrapetyan Viktoryna - Administrative Assistant		TIME VISIT/ INSPECTION COMPLETED:	03:00 PM

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On 5/7/2026 Licensing Program Analyst (LPA) Perchui Milena Khurshudyan arrived at this facility to conduct the required Annual Inspection. Upon arrival, LPA was greeted by the Staff, who granted access to the facility. LPA explained the reason for the visit. LPA Khurshudyan reviewed the required postings posted on the entrance wall and throughout the facility. Administrative Assistant Viktorya Hayrapetyan arrived shortly after. At approximately 10:05am LPA requested staff and residents’ rosters for review.

The inspection tool was used to complete the visit.

At 10:35pm LPA, with the help of the Staff, began a physical plant tour of the facility and the following was observed: This is a single-story building with four (4) bedrooms, and all rooms are designated for residents’ use only. There are three (3) bathrooms, a kitchen, common areas: living and dining rooms, and an outdoor area. Facility has an approved fire clearance for six (6) non-ambulatory residents, all of which one (1) may be bedridden for bedroom #4, and a Hospice waiver approval for six (6) residents.

Kitchen: LPA observed a seven-day supply of non-perishable food, and a two-day supply of perishable food properly stored and labeled. No expired food was observed. Facility stores knives and sharps inside the locked kitchen cabinet. Sufficient amount of emergency supply of food / water was readily available inside the kitchen cabinet. Food storage and preparation areas are clean and inaccessible to pests. LPA observed one (1) fire extinguisher located on the kitchen wall. The fire extinguisher was last serviced on 6/13/2025. Dish soap and other chemicals were observed to be stored under the sink inside the locked cabinet and inaccessible to residents in care.

Continue on LIC809-C

NAME OF LICENSING PROGRAM MANAGER: Nichelle Gillyard
NAME OF LICENSING PROGRAM ANALYST: Perchui Khurshudyan
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/07/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/07/2026

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: SAINT MARIAM SENIOR CARE	FACILITY NUMBER: 197610567
	VISIT DATE: 05/07/2026

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Bedrooms: LPA observed bedrooms to be properly furnished with beds, linens, nightstands, chairs, drawers, closets, and adequate lighting. All bedrooms appeared organized and clean. Residents have enough personal hygiene products. During the visit, the LPA observed that a bedridden resident is occupying bedroom #3; however, according to the approved fire clearance, the resident must be inside bedroom #4.

Common Areas: These include living and dining areas. LPA observed dining, living areas clean and clear of clutter. Furniture is generally new and in a good repair. Dining and living room furniture sits at the capacity of the facility. Walls, floors, windows, screens, and blinds were clean and in good repair. At 11:05am, LPA measured the room temperature to be 73 degrees Fahrenheit. There is a linen closet with an adequate supply of fresh linens ready to use. No obstructions and or tripping hazards found inside the facility. Facility has landline, LPA checked it was operational.

Bathroom: The bathrooms contained hand soap, paper towels, toilet paper and trash bins with lids. The hot water temperature was measured at approximately 11:15am to be 117.1 degrees Fahrenheit. The bathrooms were checked for cleanliness and proper operations. Towels and washcloths are not shared. LPA observed non-skid mats and grab bars inside the bathrooms.

Smoke and Carbon Monoxide Detectors: The smoke and carbon monoxide detectors were tested by staff at approximately 11:35am and were observed to be operational.

Garage: There is no garage in the property.

Laundry Room: Functioning washer and dryer is located in the separate laundry area next to the kitchen. Laundry detergents and other chemical supplies observed locked inside the laundry room cabinet.

Backyard/Front yard: LPA observed sufficient yard space and fenced backyard with appropriately covered shaded area available for residents to rest. There is outdoor furniture under the shaded area. LPA discussed the importance of maintaining care and supervision to meet the needs of clients. During the physical walk through LPA observed all exit areas to be free of clutter and obstruction. There is no body of water.

Staff/Client File review: Facility records are kept inside the locked commercial/metal cabinet located in the living room. Between 12:30pm -1:35pm LPA conducted records review of six (6) staff files and four (4) residents’ records. Files were complete and updated.

Continue On LIC809C

NAME OF LICENSING PROGRAM MANAGER: Nichelle Gillyard
NAME OF LICENSING PROGRAM ANALYST: Perchui Khurshudyan
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/07/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/07/2026

LIC809 (FAS) - (06/04)

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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: SAINT MARIAM SENIOR CARE	FACILITY NUMBER: 197610567
	VISIT DATE: 05/07/2026

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Medications: At approximately 1:30pm, LPA reviewed Centrally Stored Medication Destruction Records for proper documentation. LPA observed centrally stored medications locked inside the cabinet located in the living room and inaccessible to residents in care. Complete First-aid kit is available and is placed next to the entrance door . No potentially dangerous items were found in the facility. The facility operates with two-three (2-3) shifts and has one to two (1-2) staff members for each shift.

LPA conducted interviews with the Administrative Assistance, two caregivers and two (2) out of four (4) residents who were able to communicate and answer questions.

Facility plan/sketch is posted on the wall along with other posting requirements.

LPA collected LIC500, LIC9020, and copy of Liability Insurance, and copy of Administrator certificate at the time of the visit.

LPA also checked the Emergency Disaster Form and informed the facility to update the form and send the new copy to LPA.

The Administrator certificate will be expiring on 8/17/2026.

The Liability Insurance expires 4/30/2027.

The facility has no outstanding balance of licensing fees.

A Deficiency issued during today’s visit. See LIC809-D

Exit interview conducted, a copy of this report signed, appeal rights explained and delivered.

NAME OF LICENSING PROGRAM MANAGER: Nichelle Gillyard
NAME OF LICENSING PROGRAM ANALYST: Perchui Khurshudyan
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/07/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/07/2026

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 05/07/2026 02:52 PM - It Cannot Be Edited

Created By: Perchui Khurshudyan On 05/07/2026 at 02:11 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: SAINT MARIAM SENIOR CARE	FACILITY NUMBER: 197610567
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/07/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87202(a)(2)

87202(a)(2) All facilities shall maintain a fire clearance approved by fire dept... Prior to accepting any of the following types of persons, licensee shall obtain an appropriate fire clearance approved by fire dept, (2) Bedridden persons. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	The Licensee failed to follow Title 22 Regulations regarding approved fire clearance, by placing bedridden resident R1 to the room that had no bedridden fire clearance. This poses an immediate health and safety risk to residents in care.
	POC Due Date: 05/08/2026
	Plan of Correction
1 2 3 4	Administrator stated that R1 will be transferred to bedroom #4 per Fire Clearance approval by 5/8/2026 and will send a picture of the room change.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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:

	Perchui Khurshudyan
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/07/2026

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/07/2026

LIC809 (FAS) - (06/04)

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