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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195850075
Report Date: 11/13/2024
Date Signed: 11/13/2024 06:14:59 PM

Document Has Been Signed on 11/13/2024 06:14 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:A-1 BOARDING CAREFACILITY NUMBER:
195850075
ADMINISTRATOR/
DIRECTOR:		HOVHANNES ISPIRYANFACILITY TYPE:
740
ADDRESS:6511 BONNER AVE.TELEPHONE:
(818) 691-3146
CITY:N. HOLLYWOODSTATE: CAZIP CODE:
91606
CAPACITY: 6CENSUS: 6DATE:
11/13/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:46 PM
MET WITH:Erna Gevorgyan - Administrator Designee TIME VISIT/
INSPECTION COMPLETED:
06:25 PM
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Licensing Program Analyst (LPA) Erica Mosley arrived at the facility unannounced to conduct a required annual visit at 12:40 p.m. Upon arrival, there was two (2) staff and six (6) residents present. Staff called Administrator Designee and they arrived shortly after. The LPA met with Administrator Designee Erna Gevorgyan and explained the reason for the visit. The LPA toured the physical plant areas inside and outside to ensure there are no health and safety hazards and the facility is in compliance with Title 22 Regulations.

KITCHEN: The LPA toured the kitchen/food service area at 1:24 p.m. The hot water was measured at 106.7 degrees Fahrenheit at 1:25 p.m. The kitchen appeared clean and the appliances and fixtures functional. Refrigerated and frozen foods were stored at proper temperature. There was a sufficient amount of two (2) day perishable and seven (7) day non-perishable food. Food labels were inspected and checked for dates and expiration dates. Food had labels clearly marked with dates. Knives and sharps were observed locked in a cabinet. There were no pesticides or poisons observed near any food areas.

LIVING ROOM/DINING ROOM: The LPA inspected the living room and dining room area. The common areas were observed to be properly furnished and clean at the time of the visit. Furniture was observed to be in good condition. The facility maintained a comfortable temperature. At 5:27 p.m., the hardwired smoke detector(s) and carbon monoxide detectors were tested and operational. Fire extinguishers was observed fully charged and purchased on 01/11/24. The LPA observed required postings throughout the common spaces. The facility has a working telephone on premises. Auditory alarms on all doors were functional at the time of the visit. Entry/exits were free of obstruction. The last emergency disaster drill took place on 08/21/2024 and are conducted quarterly. Activities were observed in the common areas. An adequate supply of emergency food and water was observed in the front storage cabinets.

(Report Continued on LIC 809C...2nd page)

SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Erica Mosley
LICENSING EVALUATOR SIGNATURE: DATE: 11/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/13/2024
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
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: A-1 BOARDING CARE
FACILITY NUMBER: 195850075
VISIT DATE: 11/13/2024
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2ND PAGE

(Report Continued from LIC 809...)

OUTDOORS/ STORAGE: Located at the back of the facility is an alternate dwelling unit (ADU) that was recently added. Permits were obtained on 3/23/22 and the ADU was approved for occupancy on 6/30/23. Copy of Certificate of Occupancy was obtained today. The LPA observed a sufficient supply of Personal Protectant Equipment (PPE) in the storage unit outside. Cleaning supplies and toxins were observed in the locked laundry room inaccessible to residents in care. There is a locked laundry room with a washer and dryer on the premises. The backyard is not used by the residents in care. The front yard area has a sufficient amount of space with shaded area with furniture including a table and chairs for resident use. The LPA observed a clear passageway in case of an emergency. There were no bodies of water noted at the time of the visit.

BEDROOMS: There are four (4) total rooms. Three (3) are currently designated as shared resident bedrooms and One (1) as a storage room. The resident bedrooms were properly furnished with a bed, night stand, and sufficient lighting for each resident. The bedrooms had appropriate and adequate bedding and linens such as sheets, pillowcases, mattress pads, and blankets.

BATHROOMS: There are three (3) bathrooms one (1) for shared resident use, One (1) for private resident use and one (1) for staff but can be used in an emergency. Resident bathrooms were clean and sanitary and in operating condition with grab bars and non-skid surfaces. The hot water was measured at 108.5 degrees Fahrenheit at 1:36 p.m. for the shared bathroom and 108.0 degrees Fahrenheit at 1:44 p.m. for the private bathroom all within the required range.

(Report Continued on LIC 809C... 3RD PAGE)
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Erica Mosley
LICENSING EVALUATOR SIGNATURE:

DATE: 11/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/13/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3
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: A-1 BOARDING CARE
FACILITY NUMBER: 195850075
VISIT DATE: 11/13/2024
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3RD PAGE

(Report Continued from LIC 809C 2nd page)

RECORDS: Records review began at 1:55 p.m., six (6) resident records were reviewed for, but not limited to: appraisals, medical records, admissions agreement, consent forms. All files were in order at this time.

Four (4) Personnel records including both the Administrator and Administrator Designee’s file were reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All files were in order.


MEDICATIONS: Medications review for six (6) residents began at approximately 4:40 p.m. Medications are centrally stored in a cabinet in the kitchen locked and inaccessible to residents in care. All medications including PRNs were labeled, stored, and locked inaccessible to residents. PRNs have physicians order on file. Medications are labeled and checked for expiration dates. No medication errors observed at this time.

The LPA interviewed two (2) staff, and three (3) residents during the inspection.

During today’s visit, the LPA obtained copies of the following: LIC 500 Personnel Report, LIC 9020 Resident Roster, Certificate of Occupancy and current liability insurance.

No deficiencies cited at this time. Exit interview conducted. A copy of the report was provided.
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Erica Mosley
LICENSING EVALUATOR SIGNATURE:

DATE: 11/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/13/2024
LIC809 (FAS) - (06/04)
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