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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881617
Report Date: 08/04/2026
Date Signed: 08/04/2026 05:42:10 PM

Document Has Been Signed on 08/04/2026 05:42 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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:LUNA SENIOR SERVICESFACILITY NUMBER:
331881617
ADMINISTRATOR/
DIRECTOR:		HOVSEPIAN, SAHAKFACILITY TYPE:
740
ADDRESS:2121 E DESERT PARK AVENUETELEPHONE:
(818) 568-6812
CITY:PALM SPRINGSSTATE: CAZIP CODE:
92262
CAPACITY: 6CENSUS: 5DATE:
08/04/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:45 PM
MET WITH:Filly Demakota, StaffTIME VISIT/
INSPECTION COMPLETED:
05:50 PM
NARRATIVE
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On 8/4/2026, Licensing Program Analyst (LPA), Ahliah Sharp conducted an unannounced annual inspection. The LPA met with Caregiver Filly Demakota, who immediately called Administrator Sahak Hovsepian, to notify him that CCLD was on grounds. Demakota asked if LPA would speak with ADMIN Hovsepian on the phone, LPA Sharp notified ADMIN Hovsepian of the purpose of the visit. ADMIN Hovsepian told LPA that Caregiver Demakota the authority to sign on his behalf and could conduct the inspection.

Fire clearance is granted for six (6) ambulatory residents of which five (5) may be non-ambulatory and one (1) may be bedridden. The facility currently has five (5) residents.

The facility is composed of four (4) resident bedrooms, three (3) bathrooms, a garage, laundry room, living room, an open kitchen and dining area, and front and back yard areas. The interior and exterior walkways of the facility were observed to be clutter free with no obstructions present. Smoke and Carbon Monoxide detectors were tested and operable. New fire extinguisher is located near the kitchen area. There is a disaster plan, but facility failed to have any disaster preparedness supplies. There is a citation being issued on the attached 809D.

Swimming pool in the backyard is in compliance with a fence all around. There are no known firearms at the facility at the time of this visit. Rooms, furniture, beds, and mattresses were all in good repair. The bedrooms are furnished, and privacy is available. The dining and living room areas are clutter-free and furniture is in good condition.

Continued on LIC809-C.....

Jazmond D Harris
Ahliah Sharp
DATE: 08/04/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/04/2026
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: LUNA SENIOR SERVICES
FACILITY NUMBER: 331881617
VISIT DATE: 08/04/2026
NARRATIVE
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Continued from LIC 809...

The resident bathrooms were observed to have non-slip mats available and showers are equipped with non-slip surface. The hot water was tested and measured at 107.6 degrees Fahrenheit, which is within regulatory requirements. Outdoor areas had sufficient room for activities. A washing machine and dryer are available and in working order.

Medications were stored inaccessible to any unauthorized individuals. Designated areas are available for facility files, staff files and resident files. The first aid kit was observed to be available and complete with manual. Cleaning supplies were observed but were not stored away in a locked area. There is a citation being issued on the attached 809D. Linens, and equipment are all in good repair and sufficient for approved census.

Utensils and dishware are sufficient for the capacity. The refrigerator and stove are in working order. Sharps were stored in a locked cabinet, available only to authorized individuals.

The following signs were observed to be posted at the facility: Theft and Loss Policies, Personal Rights, Resident/Family Councils, and Complaint Information.

LPA observed that the physical plant is clean, in good repair, and to be free from debris during today’s visit. The facility received two (2) deficiencies failing to meet the requirements in accordance with Title 22, California Code of Regulations.

An exit interview was conducted, and this report, 809C, the 809 D’s were discussed and provided along with the appeal rights to Caregiver Demakota, on behalf of ADMIN Sahak Hovsepian.

NAME OF LICENSING PROGRAM MANAGER: Jazmond D Harris
NAME OF LICENSING PROGRAM ANALYST: Ahliah Sharp
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/04/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2026
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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Document Has Been Signed on 08/04/2026 05:42 PM - It Cannot Be Edited


Created By: Ahliah Sharp On 08/04/2026 at 04:42 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
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: LUNA SENIOR SERVICES
FACILITY NUMBER: 331881617

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/04/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(a)(2)
Other Provisions
(a)In addition to any other requirement of this chapter, a residential care facility for the elderly shall have an emergency and disaster plan that shall include, but not be limited to, all of the following: (2) Plans for the facility to be self-reliant for a period of not less than 72 hours immediately following any emergency or disaster, including, but not limited to, a short-term or long-term power failure. If the facility plans to shelter in place and one or more utilities, including water, sewer, gas, or electricity, is not available, the facility shall have a plan and supplies available to provide alternative resources during an outage.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above in 5 out of 5 residents which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/04/2026
Plan of Correction
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Obtaining emergency disaster supplies, including, but not limited to adequate drinking water, nonperishable food, and other necessary supplies identified in the emergency disaster plan. Train all staff on the location of the supplies, and thier role during the disaster and identify inspection to update kit and ensuring adequate upkeep of the supplies. Provide photos via email to CCLD by date of POC.
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.
Jazmond D Harris
NAME OF LICENSING PROGRAM MANAGER:
Ahliah Sharp
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/04/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/04/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/04/2026 05:42 PM - It Cannot Be Edited


Created By: Ahliah Sharp On 08/04/2026 at 04:42 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
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: LUNA SENIOR SERVICES
FACILITY NUMBER: 331881617

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/04/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space and Access
(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above in 5 out of 5 residents which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/05/2026
Plan of Correction
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Staff made the chemicals inaccessible and will review the regulation cited above and provide CCLD via email with a statement of understanding by 08/05/2026
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.
Jazmond D Harris
NAME OF LICENSING PROGRAM MANAGER:
Ahliah Sharp
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/04/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/04/2026


LIC809 (FAS) - (06/04)
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