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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610582
Report Date: 09/24/2025
Date Signed: 09/24/2025 02:52:49 PM

Document Has Been Signed on 09/24/2025 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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:DIGNITY SENIOR CARE INC.FACILITY NUMBER:
197610582
ADMINISTRATOR/
DIRECTOR:		SOGHOMONYAN, LALAFACILITY TYPE:
740
ADDRESS:10421 GERALD AVETELEPHONE:
(818) 219-6455
CITY:GRANADA HILLSSTATE: CAZIP CODE:
91344
CAPACITY: 6CENSUS: 5DATE:
09/24/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Emma Rodriguez, Staff TIME VISIT/
INSPECTION COMPLETED:
03:00 PM
NARRATIVE
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At 09:30am Licensing Program Analysts (LPAs), Angela Panushkina and Michael Cava, conducted unannounced visit to this facility in conjunction with a complaint control #31-AS-20250916083845 and #31-AS-20250919120442. LPAs were greeted by the staff, Emma Rodriguez, who granted access to the facility. LPAs attempted to contact the Administrator, but no one answered.

LPAs were informed that the facility has five (5) non-ambulatory, four (4) of which are currently receiving hospice (R1, R3, R4 and R5) and one (1) resident is receiving Home Health. Fire Clearance was approved for six (6) Ambulatory ONLY residents.

At approximately 9:35am LPAs conducted a tour of the facility, and the following were observed:

Kitchen: LPAs observed insufficient supplies of staple non-perishable for 1 week and perishable for 2 days. LPAs observed Clorox along with other chemicals and detergents under the kitchen sink were kept unlocked and accessible to residents. There is a fire extinguisher by the kitchen and LPAs observed the arrow on a meter was still on a green area, indicating that it was fully charged. Smoke alarm is operational however the carbon monoxide detector is inoperable.

Bedrooms: There are three (3) bedrooms designated for residents’ use and have sufficient lighting. All bedrooms have appropriate bedding and linens. Between 9:45am and 9:55am, LPAs observed walls to be poorly scraped up in all three (3) bedrooms. LPAs also observed R1, R2, R3, and R5 had full bed rails, and R4 had ½ bedrail. Physician's order for half/full bed rails were not available upon request.

Continue on LIC809-C

NAME OF LICENSING PROGRAM MANAGER: Nichelle Gillyard
NAME OF LICENSING PROGRAM ANALYST: Angela Panushkina
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/24/2025
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 5
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: DIGNITY SENIOR CARE INC.
FACILITY NUMBER: 197610582
VISIT DATE: 09/24/2025
NARRATIVE
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Bathrooms: At 10:00am LPAs observed two (2) bathrooms are clean, however, one (1) out of two (2) toilet bowl seats was damaged/broken. Both bathrooms were properly supplied with toilet paper, soap, and paper towels.

Medications review: At approximately 10:05am team conducted a review of medication for residents in care. LPAs were unable to review centrally stored medication and destruction records. No First Aid Kit and a manual were available for review.

Common Areas: The facility maintains a comfortable temperature at 75°F. The living room and dining area appeared clean. However, the living room lacked adequate seating, which include couches, armchairs, etc. LPAs observed only one loveseat available for residents use. LPAs also observed loveseat and dining chairs to be in poor condition (wear and tear). No obstructions observed throughout the facility. The facility license along with personal rights were posted and available for review. Smoke alarm and carbon monoxide detector were checked and observed to be operational.

Outside areas: At approximately 10:15am LPAs toured the outside area of the facility. LPAs did not observe backyard furniture to accommodate the six (6) residents. There are no body of water.

Laundry: Laundry room is located by the kitchen, and during the walk through, LPAs observed cleaning supplies were not locked.

Resident Files: At 10:00am, during the walk through, LPAs requested resident and staff file. S1 contacted an individual named Elsa and was informed that only the Administrator has access to all facility files (staff/residents). Hospice and Home Health files were also not available for review.

Staff Files: The following was observed. There is one (1) staff working for at least a month without fingerprint clearance and or association to the facility. At 10:48am, LPA contacted Elsa and was informed that the Administrator is unable to come to the facility today and there is no designee that can provide access to resident/staff files. No files were available for LPAs review upon request.

Administrative: Last notice for the annual fee was mailed on 07/02/2025 for the amount of $495.00, which is due by 10/21/2025. The Administrator is also required to submit liability insurance.

Deficiencies and civil penalty issued, see LIC809Ds.

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

NAME OF LICENSING PROGRAM MANAGER: Nichelle Gillyard
NAME OF LICENSING PROGRAM ANALYST: Angela Panushkina
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2025
LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 09/24/2025 02:52 PM - It Cannot Be Edited


Created By: Angela Panushkina On 09/24/2025 at 01:17 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: DIGNITY SENIOR CARE INC.
FACILITY NUMBER: 197610582

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/24/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87202(a)(1)
87202(a)(1) Fire Clearance: All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining (1)Nonambulatory Persons, licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal. This requirement was not met as evidenced by: LPA identified four residents that were non-ambulatory.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPAs observation and intervie, the licensee did not comply with the section cited above by accepting five (5) non-ambulatory residents without having a proper fire clearance, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/26/2025
Plan of Correction
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Licensee will complete and submit LIC200 along with the facility sketch to Fire Department for non-ambulatory approval by POC date.
Repeat violation
Type A
Section Cited
CCR
87355(e)(1)
87355(e)(1)Criminal record clearance: (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department or...

This requirement is not met as evidenced by:


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interviews and LIS review, the licensee did not comply with the section cited above, by hiring S1 on 09/22/25 and not associating with the facility, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/26/2025
Plan of Correction
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Administrator will associate S1 through the guardian (LIS) and submit an updated LIC500 to LPA by POC date
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:
Angela Panushkina
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/24/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/24/2025


LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 09/24/2025 02:52 PM - It Cannot Be Edited


Created By: Angela Panushkina On 09/24/2025 at 01:21 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: DIGNITY SENIOR CARE INC.
FACILITY NUMBER: 197610582

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/24/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87506(a)
87506(a) Resident Records: (a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPAs interview, the licensee did not comply with the section cited above by not assuring the staff has access to fcility documents to provide residents files upon request, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/01/2025
Plan of Correction
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Licensee will conduct in-service training with all staff and have spare keys available at the facility at all time. Proof of training will be submitted to LPA by POC date.
Type B
Section Cited
CCR
87412(a)
87412(a) Personnel Records: (a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:

This requirement is not met as evidenced by:



Deficient Practice Statement
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Based on LPAs interviews, the licensee did not comply with the section cited above by not assuring the staff has access to facility documents to provide staff files upon request, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/01/2025
Plan of Correction
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Licensee will conduct in-service training with all staff and have spare keys available at the facility at all time. Proof of training will be submitted to LPA by POC date.
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:
Angela Panushkina
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/24/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/24/2025


LIC809 (FAS) - (06/04)
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