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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609097
Report Date: 06/17/2026
Date Signed: 06/17/2026 02:17:12 PM

Document Has Been Signed on 06/17/2026 02:17 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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:THREE C'S CARE HOMEFACILITY NUMBER:
197609097
ADMINISTRATOR/
DIRECTOR:		LOPEZ, MILAGROSFACILITY TYPE:
740
ADDRESS:6447 BABCOCK AVENUETELEPHONE:
(818) 747-2212
CITY:NORTH HOLLYWOODSTATE: CAZIP CODE:
91606
CAPACITY: 6CENSUS: 5DATE:
06/17/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:04 AM
MET WITH:Ani Palezyan, Assistant AdministratorTIME VISIT/
INSPECTION COMPLETED:
02:00 PM
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Licensing Program Analyst (LPA) Zabel Chochian arrived at the facility to conduct a required annual visit. Upon arrival LPA met with staff Ani Palezyan and reason for the visit was explained. LPA was informed that currently the facility is under change of ownership and an application was submitted by Ani Palezyan and Sergey Karapetyan in 05/2026.

The LPA toured the physical plant areas inside and outside, with staff to ensure there are no health and safety hazards.

KITCHEN: All kitchen appliances observed in good repair and operable. The facility has a sufficient supply of perishable food and nonperishable food. Knives, medications, and chemicals were locked and inaccessible. The facilities laundry closet is located in the kitchen which was locked and inaccessible to residents at the time of the visit. BEDROOMS: There are (3) three bedrooms designated for resident use. The facility has furnished each room with clean linens, appropriate furnishings, and sufficient lighting for resident use. RESTROOMS: The LPA observed resident restrooms to be clean, sanitary, and in operating condition with grab bars and non-skid surfaces. The LPA observed sufficient amounts of soap and paper products. Restroom hot water measured between 120.9 and 115.0 degrees Fahrenheit. COMMON AREAS: The common spaces included the living room and dining area. All areas were clean, sanitary and in good repair. The LPA observed required postings on the living room wall. One fire extinguisher was observed to be fully charged and last purchased on 3/26/26. Smoke detectors and Carbon Monoxide detectors were tested and confirmed to be operable at the time of the visit.


(Continue to LIC809c)
NAME OF LICENSING PROGRAM MANAGER: Desaree Perera
NAME OF LICENSING PROGRAM ANALYST: Zabel Chochian
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 06/17/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/17/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: THREE C'S CARE HOME
FACILITY NUMBER: 197609097
VISIT DATE: 06/17/2026
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BACKYARD: Detached garage is converted to a separate living space but is being used for storage and has an additional refrigerator. The backyard free of any debris or obstructions.

RESIDENT RECORDS: At approximately 11am, LPA spoke with three residents; no concerns were noted. At approximately 11:45am, LPA reviewed five (5) residents' files and all were complete. Documents reviewed included, but were not limited to, physician's reports, admission agreements, personal rights, and needs and services plans.



STAFF RECORDS: At approximately 12:30pm, LPA reviewed four (4) staff files and all were complete. Documents reviewed included, but were not limited to, training records, TB test results, health screenings, and fingerprint background clearance.

MEDICATIONS: At approximately 1:15pm, LPA reviewed medications which are stored in the locked cabinet in the kitchen. The facility has Centrally Stored Medication and Destruction Records (CSMDR) which were complete. LPA reviewed three (3) residents medications with staff. The medications reviewed appeared to be given as prescribed and the medications were properly labeled and stored. The first aid kit was observed complete with manual.

LPA reviewed facility’s policies and procedures as it pertains to infection control and emergency disaster. Both were reviewed by staff in 3/2026. Last disaster drill was conducted on 6/5/2026.

LPA requested a current copy of the facility Personnel Report - LIC500 and Liability Insurance be sent to the Regional office. Staff Ani P. stated that she will send copies today.


No deficiencies cited. Exit interview conducted. A copy of today's report was provided.

NAME OF LICENSING PROGRAM MANAGER: Desaree Perera
NAME OF LICENSING PROGRAM ANALYST: Zabel Chochian
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/17/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2026
LIC809 (FAS) - (06/04)
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