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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195850464
Report Date: 10/05/2026
Date Signed: 10/05/2026 03:25:03 PM

Document Has Been Signed on 10/05/2026 03:25 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 N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:VALLEY GLEN SENIOR LIVING INCFACILITY NUMBER:
195850464
ADMINISTRATOR/
DIRECTOR:		AYVAZYA, SARGISFACILITY TYPE:
740
ADDRESS:7054 VANSCOY AVETELEPHONE:
(747) 253-0007
CITY:NORTH HOLLYWOODSTATE: CAZIP CODE:
91605
CAPACITY: 6CENSUS: 6DATE:
10/05/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:15 AM
MET WITH:Sargis AyvazyanTIME VISIT/
INSPECTION COMPLETED:
03:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Trevor Byrne arrived at the facility unannounced to conduct the required annual visit at 10:15 AM. LPA met with facility staff who contacted the Administrator Sargis Ayvazyan. The Administrator arrived to the facility at approximately 12:00 PM. Entrance interview was conducted and the reason for the visit was explained.

Beginning at approximately 10:20 AM, the LPA, along with facility staff, toured the physical plant areas inside and outside to ensure there are no health and safety hazards, and that facility is in compliance with Title 22 Regulations. The following was observed:

KITCHEN: LPA observed the kitchen area to be clean. Kitchen appliances appeared to be in operable condition. The facility had a sufficient supply of two (2) days perishable and seven (7) days non-perishable food. LPA observed a secured drawer which contained knives and other sharp objects. LPA observed a secured cabinet located under the sink which contained cleaning supplies. LPA observed the kitchen to contain a wall mounted fire extinguisher that was fully charged and was last serviced on 08/26/2026. LPA observed the kitchen to contain adequate emergency food and water supplies. Additionally, the kitchen contained the facility's complete first aid kit

CONTINUED ON LIC 809C.

Kasandra Lopez
Trevor Byrne
DATE: 10/05/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/05/2026
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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Document Has Been Signed on 10/05/2026 03:25 PM - It Cannot Be Edited


Created By: Trevor Byrne On 10/05/2026 at 02:43 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. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: VALLEY GLEN SENIOR LIVING INC
FACILITY NUMBER: 195850464

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/05/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87355(e)(3)
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: (3) Request a transfer of a criminal record clearance as specified in Section 87355(c) or

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above as S1 did not have the required association to the facility or a submitted criminal background clearance transfer request which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/06/2026
Plan of Correction
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Administrator agreed to associate S1 to the facility and to provide proof of S1's association to CCLD no later than POC due date.
Type A
Section Cited
CCR
87203
87203 Fire Safety
All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation the licensee did not comply with the section cited above as two (2) bedrooms had their fire alarms removed with wires exposed which poses an immediate health and safety risk to persons in care.
POC Due Date: 10/05/2026
Plan of Correction
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Administrator had working fire alarms installed in both bedrooms during the visit. POC cleared.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Kasandra Lopez
NAME OF LICENSING PROGRAM MANAGER:
Trevor Byrne
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/05/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/05/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/05/2026 03:25 PM - It Cannot Be Edited


Created By: Trevor Byrne On 10/05/2026 at 02:43 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. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: VALLEY GLEN SENIOR LIVING INC
FACILITY NUMBER: 195850464

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/05/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(g)
Personnel Records
(g) All personnel records shall be maintained at the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above as one employee file was not located at the facility for review which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/19/2026
Plan of Correction
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Administrator agreed to provide proof of the employee file at the facility to CCLD no later than POC due date.
Type B
Section Cited
CCR
87465(h)(6)
87465 Incidental Medical and Dental Care
(h) The following requirements shall apply to medications which are centrally stored:
(6) The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least one year and includes:
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above as two resident CSMDRs were missing prescribed medications and information including but not limited to dates filled and expiration dates which poses a potential health risk to persons in care.
POC Due Date: 10/19/2026
Plan of Correction
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Administrator agreed to log the missing/inaccurate information onto the resident's CSMDRs and to provide proof of the updated CSMDRs to CCLD no later than POC due 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.
Kasandra Lopez
NAME OF LICENSING PROGRAM MANAGER:
Trevor Byrne
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/05/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/05/2026


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 N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: VALLEY GLEN SENIOR LIVING INC
FACILITY NUMBER: 195850464
VISIT DATE: 10/05/2026
NARRATIVE
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COMMON AREAS: This included the living room, entryway, office, hallway, and dining area. LPA observed the living room to be clean and properly furnished at the time of the visit. The living room contained activities and a television for resident use. Additionally, the living room contained a secured closet which contained resident medications. LPA observed the entryway to contain all required postings. LPA observed the office to be locked and inaccessible to clients in care. The office contained facility, resident, and staff files. LPA observed the hallway to be clean and free from obstructions. The dining area was observed to contain adequate seating for resident use. All furniture in the facility was observed to be clean and in good repair. LPA observed cameras located throughout the common areas of the facility. LPA confirmed with the Administrator that audio is not recorded. Smoke detectors and carbon monoxide detectors were tested at 11:06 AM and were functional at the time of the visit.

BEDROOMS: There are six (6) bedrooms in the facility. Five (5) are designated for resident use and one (1) is a staff bedroom. LPA and facility staff toured all bedrooms. All resident rooms were observed to be furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting. All bedrooms contained direct exits to the outdoors of the facility. Auditory alarms were observed on facility exits and all were functional at the time of the visit. LPA observed bedrooms #2 & 6 to be missing installed fire alarms with wires exposed. LPA informed facility staff and later the Administrator that this is a zero-tolerance violation and constitutes a violation of the facility’s fire clearance. LPA informed the Administrator that a civil penalty in the amount of $500 is being assessed on today’s date (10/05/2026) for a fire clearance violation. The Administrator had working fire alarms installed in both bedrooms during the visit.

BATHROOMS: There are three (3) bathrooms at the facility. Two (2) are designated as shared resident bathrooms and one (1) is designated as a staff bathroom. All bathrooms were observed to be clean and in good repair and all were equipped with nonskid surfaces. Grab bars were observed in all bathrooms and all were properly secured. The water temperature was measured to be between 105.8 and 112.8 degrees Fahrenheit, which is within the range required by regulation.

OUTDOOR SPACE: The facility had two (2) emergency exit gates located in the front and back yard of the property; LPA observed clear passageways for emergency exit use. The facility had adequate shaded seating outdoors for resident use. The backyard contained one (1) secured shed. LPA observed cameras located throughout the outdoors of the facility.

CONTINUED ON LIC 809C.

NAME OF LICENSING PROGRAM MANAGER: Kasandra Lopez
NAME OF LICENSING PROGRAM ANALYST: Trevor Byrne
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/05/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2026
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 N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: VALLEY GLEN SENIOR LIVING INC
FACILITY NUMBER: 195850464
VISIT DATE: 10/05/2026
NARRATIVE
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RECORD REVIEW: Record review began at 11:15 AM. Staff and resident records were reviewed for documents including, but not limited to: health screening, TB test, staff training records, fingerprint clearance, resident physician's report, needs and service appraisal, consent forms, and personal rights. Two (2) staff files were reviewed. All staff files contained the required documents and trainings. LPA observed that staff #1 (S1) was not be associated to the facility. LPA requested to review S1’s personnel file. The Administrator informed LPA that S1 was associated to their other facility and only covers at this facility in case of emergency. The Administrator stated that S1 began employment at this facility approximately one (1) month ago. The Administrator stated that S1’s file was located at the other facility and a copy was not available for review. LPA informed the Administrator that all personnel records shall be maintained at the facility and shall be available for review. Additionally, LPA informed the Administrator that prior to working, residing or volunteering in a licensed facility employees shall obtain a criminal record clearance or request a transfer of a criminal record clearance and have association to the facility. LPA informed the Administrator that because S1 was present and working in the facility without the required association to the facility or a submitted criminal background clearance transfer request a civil penalty in the amount of $500 ($100/day x 5 days = $500) is being assessed on today’s date (10/05/2026). Six (6) resident files were reviewed. All resident files contained all required documentation.

MEDICATION REVIEW: Medication review began at 01:55 PM. Medications are stored centrally and securely in a cabinet in the living room. Medications for two (2) residents were observed. LPA observed multiple medications to have inaccurate/missing information recorded on their respective centrally stored medication and destruction record sheets (CSMDRs) including expiration dates and dates filled. Additionally, LPA observed two (2) medications to not be logged on their respective CSMDRs.

INFECTION CONTROL/EMERGENCY DISASTER PLANNING: During today’s visit, the LPA reviewed the facility's infection control practices and the facility's emergency disaster plan. The facility’s policies and procedures as they pertain to infection control are adequate. Emergency disaster drills are conducted quarterly; the facility’s last emergency disaster drill was conducted on 07/15/2026. The facility’s emergency disaster plan is up to date and is adequate. Both the infection control plan and the emergency disaster plan are reviewed/updated annually by the facility’s Administrator.

CONTINUED ON LIC 809C.

NAME OF LICENSING PROGRAM MANAGER: Kasandra Lopez
NAME OF LICENSING PROGRAM ANALYST: Trevor Byrne
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/05/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2026
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 N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: VALLEY GLEN SENIOR LIVING INC
FACILITY NUMBER: 195850464
VISIT DATE: 10/05/2026
NARRATIVE
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INTERVIEWS: LPA interviewed one (1) staff and two (2) residents. One (1) resident interviewed stated that the staff treat them well and are attentive to their needs and reported no concerns with the facility. One (1) resident interviewed reported concerns with the facility. The staff member interviewed was knowledgeable on their role and responsibilities, the resident’s rights, and the appropriate reporting procedures for suspected abuse but struggled to appropriately identify the different forms of abuse.

During today’s visit LPA obtained a copy of the facility’s updated emergency disaster plan, LIC 500, resident roster, and liability insurance.

Pursuant to Title 22 of the CA Code of Regulations and/or the Health and Safety Code, the following deficiencies were cited and civil penalties were assessed (refer to LIC 809-D). Exit interview conducted and copy of the report was issued and appeal rights provided.

NAME OF LICENSING PROGRAM MANAGER: Kasandra Lopez
NAME OF LICENSING PROGRAM ANALYST: Trevor Byrne
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/05/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2026
LIC809 (FAS) - (06/04)
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