197610823-8-31-2026-31-AS-GSAO-DXGQP7-20260831122017

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610823
Report Date: 08/31/2026
Date Signed: 08/31/2026 12:20:25 PM

COMPREHENSIVE INSPECTION

Document Has Been Signed on 08/31/2026 12:20 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:	RM GOLDEN CARE		FACILITY NUMBER:	197610823
ADMINISTRATOR/ DIRECTOR:	SARGSYAN, MAYA		FACILITY TYPE:	740
ADDRESS:	17125 Sunderland DR		TELEPHONE:	(818) 486-6352
CITY:	Granada Hills	STATE: CA	ZIP CODE:
CAPACITY: 6		CENSUS: 5	DATE:	08/31/2026
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:20 AM
MET WITH:	Maya Sargsyan, Administrator		TIME VISIT/ INSPECTION COMPLETED:	12:25 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 08/31/26, at 09:20AM, Licensing Program Analyst (LPA) Gina Saucedo arrived at the facility to conduct an unannounced, annual visit. LPA met with conducted administrator/licensee, Maya Sargsyan. LPA asked for the census, resident, and staff files. This facility is a one story building. A fire clearance is for five (5) non-ambulatory residents and one (1) bedridden resident, for a total capacity of six (6). The smoke alarms and carbon monoxide detector are dual, hard wired and inter-connected. The facility has one (1) new fire extinguisher located by the kitchen. It was purchased on May 2026. A tour of the physical plant was initiated at approximately 9:45am and the following was observed: KITCHEN: The facility has a Kitchen area that is equipped with a refrigerator, stove/oven and sink. Knives is kept locked in a kitchen drawer on your left hand side. Cleaning supplies/detergents will be kept locked underneath the kitchen sink. Medications are kept locked and inaccessible in a upper kitchen cabinet BEDROOMS: There are five (5) Rooms. Four (4) bedrooms are designated for resident use. One (1) room is utilized as staff office. Two (2) bedrooms are shared and two (2) other bedrooms are single, occupied. All bedrooms have beds, sheets, televisions and working lights. LIC 809-C-continued

Troy Agard
Gina Saucedo
	DATE: 08/31/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2026

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: RM GOLDEN CARE	FACILITY NUMBER: 197610823
	VISIT DATE: 08/31/2026

NARRATIVE

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BATHROOMS: The facility has two and a half (2 1/2) bathrooms. The two bathrooms, designated for resident use were observed to have proper fixtures, grab bars, and non-skid mats. The hot water temperature measured between 116.4 degrees. The half bathroom is for staff use only no shower is in this bathroom.

Living Room/Dining Room Area: LPA toured all common areas to insure everything is in good repair. Both living room and dining room have sufficient space and lighting. Floors were clean and maintained. Entrance/exits are clear of obstruction.

Laundry/Washer/dryer: are located in the garage area.

Administration: LPA reviewed five (5) resident files and two (2) staff files. The administrative license expires 08/2028 and the liability expires on 02/2027. The fire/evacuation drill was last conducted in 08/2026. There are signs against the wall YES, Ombudsman, Family Council, Rights of Resident Council, Theft and Loss Policies and Rights of Resident Councils.

Outside areas: LPAs toured the outside area of the facility to insure the front and back yards of the facility is clear of obstruction. There is sufficient yard space to keep outdoor furniture and hold outdoor activities at the backyard. Passageway/exits to both side gates are free of any hazards. There is no swimming pool or any other bodies of water.

Garage: The garage is detached from the building. Entrance is through the main front. There is also a backdoor to the garage, located at the backyard. Both doors to garage will be kept locked at all times. There is an extra refrigerator and the pantries have extra canned goods. There is also incontinent supplies.

An exit interview was conducted, no citation(s) were issued, and a copy of this report was given to the administrator.

NAME OF LICENSING PROGRAM MANAGER: Troy Agard
NAME OF LICENSING PROGRAM ANALYST: Gina Saucedo
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 08/31/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2026

LIC809 (FAS) - (06/04)

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