197609490-6-8-2026-31-AS-NSHN-DUUTUT-20260608150252

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609490
Report Date: 06/08/2026
Date Signed: 06/08/2026 03:03:09 PM

Document Has Been Signed on 06/08/2026 03:03 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:	BURBANK VILLA INC		FACILITY NUMBER:	197609490
ADMINISTRATOR/ DIRECTOR:	SARKISYAN, SEROP		FACILITY TYPE:	740
ADDRESS:	2324 REESE PL		TELEPHONE:	(323) 610-0000
CITY:	BURBANK	STATE: CA	ZIP CODE:	91504
CAPACITY: 6		CENSUS: 6	DATE:	06/08/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:45 AM
MET WITH:	Serop Sarkisyan-Administrator		TIME VISIT/ INSPECTION COMPLETED:	03:00 PM

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Licensing Program Analyst (LPA) Nadia Shahbazian, conducted an unannounced annual inspection at the facility mentioned above. LPA met with the Administrator Serop Sarkisyan and Coadministrator Gayane Vardanyan explained the reason for the visit. The Residential Care Facility for the Elderly (RCFE) is approved for six (6) non-ambulatory residents with hospice waiver for three (3) residents. This facility is vendorized by Frank Lanterman Regional Center.

Physical tour was conducted with the Co-Administrator at approximately 10:20am and LPA observed the following: The required posting were observed by the entry door and office area. The smoke/carbon monoxide detectors are dual, hardwired and interconnected. At 10:35am smoke/carbon monoxide detectors were tested and observed to be functional. There is a fully charged fire extinguisher located in the kitchen, purchased today on 06/08/26. Facility conducts monthly emergency and disaster drills. The last earthquake drill was conducted on 06/02/26 and the last fire drill was conducted on 05/02/26.

COMMON AREAS: The facility has an open concept living and dining area, accessed at the front door. Living/dining areas are furnished with couches, dining table/chairs, two massage chairs and television. Facility has land line telephone, internet and wi-fi access for resident's use. The living area has a ramp, leading to a hallway with an exit. Facility uses the hallway exit as the emergency exit but there is another exit door in the kitchen with two side gates at the front.

KITCHEN: Appliances and work surfaces are clean and sanitary. LPA found a sufficient amount of perishable (2 days) and non-perishable (7 days) food, properly stored in cabinets and refrigerator. There is a water filtering system, underneath the kitchen sink. Knives were stored in a locked drawer in the kitchen. Washing machine and dryer are located in the kitchen; all kitchen detergents and laundry chemicals were stored locked in a kitchen cabinet.

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NAME OF LICENSING PROGRAM MANAGER: Mary G Flores
NAME OF LICENSING PROGRAM ANALYST: Nadia Shahbazian
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 06/08/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/08/2026

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: BURBANK VILLA INC	FACILITY NUMBER: 197609490
	VISIT DATE: 06/08/2026

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BEDROOMS/BATHROOMS: There are six (6) private bedrooms designated for residents' use. Bedrooms were observed to be properly furnished with chairs, beddings and linens with sufficient lighting. There are two (2) bathrooms designated for residents' use. Bathrooms had functional fixtures and non-skid mats. Hot water temperature was measured between 113.4 and 119.3 degrees Fahrenheit.

OFFICE/MEDICAL AREA: Facility's office area is located on one corner of the dining area but all records are kept locked in the medication cabinet in the hallway. LPA counted the medications for five (5) residents and compared to Medication Administration Records (MAR) for accuracy of administration. Currently one of the residents is in a rehabilitation center due to a scheduled surgery and resident's medication was sent with them. LPA observed a complete first aid kit and first aid manual in the medication cabinet.

SURROUNDING GROUNDS: The driveway, passageways and entrance to the home is free of obstruction and hazards. The facility has outdoor covered patio with furniture including tables, chairs and umbrella. The facility does not have a swimming pool or any other bodies of water. The attached garage is located at the front and is currently used to store emergency water and supplies.

RESIDENT FILES: LPA conducted a file review of all six (6) resident records to insure compliance of licensing forms. All physician records and assessments were current and reports are complete. P&I for four (4) residents were counted and compared to receipts. Two (2) of the residents' P&I are handled by their family, therefore LPA was unable to count the P&I.

STAFF FILES: LPA also conducted a file review of four (4) staff records to insure forms and training are up to date and records are in compliance with licensing forms.

REQUIRED REPORTS/DOCUMENTS: LPA reviewed the facility's Infection Control Plan, Emergency and Disaster Plan. Surety Bond expires on 02/20/27 and Liability Insurance expires on 05/09/27. Administrator Certificate expires on 05/12/27.

Pursuant to Title 22 Division 6 of the CA Code of Regulations, there were no deficiencies observed during the visit.

Exit Interview Conducted and a Copy of this Report provided.

NAME OF LICENSING PROGRAM MANAGER: Mary G Flores
NAME OF LICENSING PROGRAM ANALYST: Nadia Shahbazian
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 06/08/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/08/2026

LIC809 (FAS) - (06/04)

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