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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610830
Report Date: 05/29/2026
Date Signed: 05/29/2026 05:06:53 PM

Document Has Been Signed on 05/29/2026 05:06 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:ADASTRA ADULT CAREFACILITY NUMBER:
197610830
ADMINISTRATOR/
DIRECTOR:		MASTOV, ARIELFACILITY TYPE:
740
ADDRESS:10747 GOTHIC AVE.TELEPHONE:
(323) 327-8554
CITY:GRANADA HILLSSTATE: CAZIP CODE:
91344
CAPACITY: 6CENSUS: 0DATE:
05/29/2026
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:45 AM
MET WITH:Mastov Ariel - Administrator TIME VISIT/
INSPECTION COMPLETED:
12:15 PM
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On 5/29/2026 at 10:00am Licensing Program Analyst (LPA) Perchui Milena Khurshudyan conducted an announced Pre-Licensing Inspection at the facility. Upon arrival LPA met with the Administrator Mastov Ariel, introduced herself showing the department badge and conducted an entrance interview.

Fire Clearance was approved on 4/24/2026 for a maximum capacity of six (6) residents, of which four (4) can be non-ambulatory bedroom #s 2, 3, 4, 5, 6, one (1) ambulatory for bedroom #1, and one (1) bedridden for bedroom #6 only. This is a single-story house with six (6) bedrooms and three (3) bathrooms. All bedrooms are designated for residents’ use only. Facility will have an awake night shift staff on premises. At 10:20am a physical plant was toured inside and out of the property with the assistance of the Administrator and the following was observed:

KITCHEN: The facility has a Kitchen area that is equipped with a new refrigerator, microwave oven and sink.

At 10:25AM, LPA observed adequate supplies of nonperishable food properly stored in the cabinets and inside the supply room. Perishable food items are not required at this time as there are no residents in the facility. LPA observed dining ware to accommodate a maximum capacity of six (6) residents. All knives and sharps are observed to be locked inside a commercial cabinet located in the kitchen area and inaccessible to residents in care. The facility has one (1) new fire extinguisher, which was purchased on 5/29/2026.

Continue on LIC809-C

NAME OF LICENSING PROGRAM MANAGER: Nichelle Gillyard
NAME OF LICENSING PROGRAM ANALYST: Perchui Khurshudyan
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/29/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/29/2026
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: ADASTRA ADULT CARE
FACILITY NUMBER: 197610830
VISIT DATE: 05/29/2026
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Laundry Area: A functioning washer and dryer are located in the garage. Disinfectants, laundry detergents, and hygiene supplies were stored securely inside a locked cabinet and were inaccessible to clients.

COMMON AREAS: At 10:35am LPA observed the living/family room and dining room furniture to be clean and in good repair. The facility maintains a comfortable temperature at 69°F. The air conditioner is operational. No firearms observed or will be maintained on the premises. Licensee has ordered puzzles, books, balls, and board games to provide activities to clients in care. No obstructions and or tripping hazards observed throughout the facility.

Bedrooms: There are six (6) bedrooms in the facility designated for residents’ use only. Bedrooms are furnished and well equipped with beds, nightstands, chairs, dresser, bedding, pillowcase, mattress pad, and blankets; extra linen is available inside the linen closet located in the hallway. Rooms were observed to have sufficient lighting and closet space. LPA observed appropriate window screens. Sufficient supplies of personal hygiene products stored in the storage area and will be provided to the clients by the Licensee. Facility will have an awake staff.

BATHROOMS: The facility has three (3) bathrooms, all bathrooms are designated for residents’ use. Bathrooms were observed to have the proper fixtures, grab bars, and non-skid mats. The hot water delivered in the bathrooms measured at 10:55am to be 109.9F degrees.

SMOKE DETECTORS/CARBON MONOXIDE. Smoke detectors and carbon monoxide were located throughout the facility. At 11:30am they were tested and observed to be operational. Facility has phone which was checked at 11:50am to be operational.

Medications: LPA observed medications will be kept centrally stored and locked inside the commercial cabinet next to the kitchen area. The key cannot be accessible to residents in care. Clients and staff files will also be kept inside the commercial cabinet.

Continue on LIC809-C

NAME OF LICENSING PROGRAM MANAGER: Nichelle Gillyard
NAME OF LICENSING PROGRAM ANALYST: Perchui Khurshudyan
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/29/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/29/2026
LIC809 (FAS) - (06/04)
Page: 3 of 4
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: ADASTRA ADULT CARE
FACILITY NUMBER: 197610830
VISIT DATE: 05/29/2026
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SURROUNDING GROUNDS: The facility has sufficient yard space. LPA observed the backyard with appropriate outdoor furniture and covered shaded areas for clients. LPA discussed the importance of maintaining care and supervision to meet the needs of clients. LPA observed that the pool on the premises was gated, equipped with a self-closing mechanism, and will remain locked at all times. During the physical walk
through LPA observed all exit areas to be free of clutter and obstruction.

GARAGE: There is a garage on the property that is currently being used for storage and contains installed laundry machines. The garage is accessible from the kitchen area, and the door will remain locked at all times.

Component III was conducted with the Licensee/Administrator.

Facility is in compliance with Title 22 Regulations at this time. This report will be forwarded to the Centralized Application Bureau (CAB) and will be notified by the CAB Analyst when the license has been approved.

LPA collected copy of the Administrator Certificate – Exp date: 12/23/2026

LPA also informed Administrator to update the new form of the Emergency Disaster Plan and submit it to the department.

Exit interview was conducted, a copy of this report signed and delivered to the Administrator.

NAME OF LICENSING PROGRAM MANAGER: Nichelle Gillyard
NAME OF LICENSING PROGRAM ANALYST: Perchui Khurshudyan
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/29/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/29/2026
LIC809 (FAS) - (06/04)
Page: 4 of 4