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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610931
Report Date: 06/19/2026
Date Signed: 06/26/2026 01:06:33 PM

Document Has Been Signed on 06/26/2026 01:06 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:HIHOME LLCFACILITY NUMBER:
197610931
ADMINISTRATOR/
DIRECTOR:		SHAGHAGHI, SARINAFACILITY TYPE:
740
ADDRESS:17337 SEPTO STREETTELEPHONE:
(818) 456-9806
CITY:NORTHRIDGESTATE: CAZIP CODE:
91325
CAPACITY: 6CENSUS: 0DATE:
06/19/2026
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:30 PM
MET WITH:Shaghaghi Sarina - Administrator TIME VISIT/
INSPECTION COMPLETED:
03:30 PM
NARRATIVE
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On 6/19/2026, at 12:30PM, Licensing Program Analyst (LPA) Perchui Milena Khurshudyan conducted an announced Pre-licensing visit. LPA met with the Administrator, Shaghaghi Sarina and introduced herself by showing her department badge.

An application was submitted to Community Care Licensing Division-CCLD on 10/08/2025, Initial license for a Residential Care Facility for the Elderly (RCFE), 60 years and older. The requested capacity is for five (5) non-ambulatory and one ambulatory, a total of up to six (6) residents. The fire clearance was approved on 01/28/2026.

Structure: The facility is a single-story building with five (5) bedrooms and three and half (3.5) bathrooms. There is a designated staff room. Hospice waiver requested for two (2) residents.

Entrance: Upon entrance, required postings such as: Personal Rights of Residents, Long-Term Care Ombudsman, and See Something Say Something were observed.

Common Areas: The common areas include: the living room and the dining room. The rooms were observed to be neat, clean, and organized with sufficient seating for both residents and staff. The rooms were observed to be properly furnished and in good repair. The facility maintains a comfortable temperature of seventy-four (74) degrees. No firearms were observed or will be maintained on the premises. LPA observed a working telephone to be located in the kitchen area.

Resident/staff files: The resident and staff files will be kept inside the locked office/staff room. Residents won’t have access to the staff room.

LIC809C-continued

NAME OF LICENSING PROGRAM MANAGER: Nichelle Gillyard
NAME OF LICENSING PROGRAM ANALYST: Perchui Khurshudyan
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 06/19/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/19/2026
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: HIHOME LLC
FACILITY NUMBER: 197610931
VISIT DATE: 06/19/2026
NARRATIVE
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Medications: The medication will be stored in a locked cabinet located near the kitchen along with a First-aid kit. Medication storage was observed to be equipped with a lock to ensure medications will not be accessible to residents.

Kitchen: The kitchen was observed to be equipped with sufficient supplies of dishes, cups, and silverware located within the kitchen cabinets and drawers. Sufficient supplies of seven (7) day nonperishable food were observed. Perishable food items are not required at this time as there are no residents in the facility. Sharps were observed to be stored in kitchen drawer, locked and inaccessible to the residents. The cleaning solutions and toxins were observed to be kept locked in cabinet underneath the kitchen sink. Kitchen appliances were observed to be working and in proper condition.

Emergency: The Fire extinguisher was observed to be located near the kitchen and dated 1/13/2026.

Bedrooms: The bedrooms were observed to be properly furnished with bed, nightstand, applicable lighting, and seating. Window coverings are in good repair, not broken or damaged.

Bathroom: The bathrooms were observed to be in proper condition. Towels and washcloths will not be shared. Appropriate grab-rails and slip-resistant mats were observed and in proper condition.

Hallways: The hallway was observed to be properly lighted. LPA observed extra linens/covers stored inside the hallway closet and inside each bedroom closet.

Laundry: The laundry appliances were observed to be located in a separate closet near the living area. Dryer and washer were observed to be in proper condition. LPA observed cleaning solutions and toxins to be located and stored appropriately within a locked storage unit and inaccessible to residents.

GARAGE: LPA observed that the garage is attached to the house and has access from the hallway near bedrooms #1 and #2. The garage will be used for storage. Emergency supply of food and water was stored and readily available.

Water Temperature: The water temperature was measured in the bathrooms and observed to be within regulations 110.3F.

LIC809C-continued

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

DATE: 06/19/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2026
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: HIHOME LLC
FACILITY NUMBER: 197610931
VISIT DATE: 06/19/2026
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Smoke detectors: The smoke detectors and carbon monoxide were observed to be working properly and were tested at 2:10 pm.

Outside: The outside was observed to be clean, free of hazards, and properly furnished with sufficient seating. LPA observed pool in the premises to be properly fenced and locked.

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: 4/7/2027.

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: 06/19/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2026
LIC809 (FAS) - (06/04)
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