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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195850089
Report Date: 02/19/2025
Date Signed: 02/19/2025 02:44:56 PM

Document Has Been Signed on 02/19/2025 02:44 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:MARY ELLEN HOMESFACILITY NUMBER:
195850089
ADMINISTRATOR/
DIRECTOR:		KHACHATRYAN, GOHARFACILITY TYPE:
740
ADDRESS:7752 MARY ELLEN AVENUETELEPHONE:
(818) 279-1415
CITY:NORTH HOLLYWOODSTATE: CAZIP CODE:
91605
CAPACITY: 6CENSUS: 5DATE:
02/19/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:26 AM
MET WITH:Gohar KhachatryanTIME VISIT/
INSPECTION COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Trevor Byrne arrived at the facility unannounced to conduct a required annual visit at 09:26 AM. LPA met with Administrator Gohar Khachatryan. Entrance interview conducted and the reason for the visit was explained.

Beginning at 09:27 AM, the LPA, along with facility Administrator 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: The LPA observed the kitchen area to be clean. Kitchen appliances appeared to be in operable condition. The facility has a sufficient supply of two (2) days perishable and seven (7) days non-perishable food. LPA observed a secured drawer to contain knives and other sharp objects.

COMMON AREAS: This includes the living room, hallway, and dining area. The living room was observed to be clean and in good repair and contained adequate seating for resident use. The living room contained an adequately screened fireplace and activities for resident use. LPA observed a fire extinguisher mounted in the living room to be fully charged and purchased on 01/22/2025. LPA observed a properly secured medication cart to contain resident medications and a mini refrigerator for medications requiring refrigeration. LPA observed one (1) hallway closet to contain extra linens. LPA observed one (1) additional hallway closet to be appropriately secured making it inaccessible to residents in care. LPA observed this closet to contain the facility’s washer and dryer along with cleaning and laundry chemicals. LPA observed the dining area to be clean and properly furnished at the time of the visit. The dining area contains a dining table with adequate seating for resident use. The facility’s combination fire and carbon monoxide alarms were tested at 09:54 AM and were functional at the time of the visit. All exits in the facility were observed to contain functioning auditory alarms.
Continued on LIC 809C.
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Trevor Byrne
LICENSING EVALUATOR SIGNATURE: DATE: 02/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/19/2025
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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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: MARY ELLEN HOMES
FACILITY NUMBER: 195850089
VISIT DATE: 02/19/2025
NARRATIVE
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BEDROOMS: There are four (4) bedrooms in the facility; two (2) are a dual occupancy resident rooms and two (2) are single occupancy resident rooms. LPA and facility administrator toured all four (4) bedrooms. All resident rooms were observed to be furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting. Bedroom #4 is the bedridden approved room and contains a direct exit to the backyard of the facility.

BATHROOMS: There are two (2) bathrooms at the facility. One (1) bathroom is designated as private resident bathroom, and one (1) bathroom is designated as a shared resident bathroom. Both resident bathrooms were observed to be clean and in good repair and were equipped with nonskid surfaces. Grab bars were observed in all resident showers and near all resident toilets, all were properly secured. The water temperature was measured between 118.2 and 118.9 degrees Fahrenheit, which is in compliance with regulation.

OUTDOOR SPACE: The facility has two (2) emergency exit gates. Both are located in the front yard; LPA observed clear passageways for emergency exit use. The facility has adequate shaded seating outdoors for resident use. LPA observed the facility’s backyard to contain two (2) extra refrigerators and two (2) storage sheds. One (1) shed was observed to be appropriately secured and contained gardening supplies. The additional shed was observed to contain extra care supplies.

RECORD REVIEW: Record review began at 10:00 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. Three (3) staff files were reviewed. All staff files contained the required documents and trainings. Five (5) resident files were reviewed. Two (2) resident files were observed to be missing negative Tuberculosis (TB) tests. One (1) resident’s physician report indicated that the resident was unable to leave the facility unassisted. At the time of the inspection LPA did not observe the resident in the facility. The Administrator informed LPA that the resident goes on walks by themselves in the mornings and confirmed that a staff member was not accompanying the resident. LPA informed the Administrator that this resident is unable to leave the facility unassisted. The Administrator and agreed to follow the physician’s orders until a licensed medical professional re-evaluates the resident’s ability to leave the facility unassisted.
Continued on LIC 809C.
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Trevor Byrne
LICENSING EVALUATOR SIGNATURE:

DATE: 02/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/19/2025
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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: MARY ELLEN HOMES
FACILITY NUMBER: 195850089
VISIT DATE: 02/19/2025
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MEDICATION REVIEW: Medication review began at 11:57 AM. Medications for five (5) of five (5) residents were observed. All medications were stored properly and were appropriately documented on their respective centrally stored medication and destruction record sheets. LPA observed three (3) resident’s medications to be prepared for the week utilizing Monday-Sunday medication organizers. LPA informed the Administrator that transferring medications between containers is not permitted. The Administrator removed the medications from the organizers and agreed to not prepare resident medications more than 24 hours in advance.

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 it pertains to infection control are adequate. Emergency disaster drills are conducted quarterly; the facility’s last emergency disaster drill was conducted on 01/18/2025. 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.

INTERVIEWS: LPA interviewed two (2) residents. The residents interviewed stated that the staff treat them very well and are attentive to their needs. Both residents had no concerns or recommendations for improvement for the facility. LPA interviewed one (1) staff member. The staff member interviewed was knowledgeable on the resident’s rights, the forms of abuse, and the appropriate reporting procedures for suspected abuse.

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

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

SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Trevor Byrne
LICENSING EVALUATOR SIGNATURE:

DATE: 02/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/19/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/19/2025 02:44 PM - It Cannot Be Edited


Created By: Trevor Byrne On 02/19/2025 at 01:44 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: MARY ELLEN HOMES
FACILITY NUMBER: 195850089

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/19/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(h)(5)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers.

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 three resident's medications were prepared one week in advance utilizing a Monday-Sunday pill organizer which poses a potential health or safety risk to persons in care.
POC Due Date: 02/19/2025
Plan of Correction
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Administrator removed the pills from the organizers at the time of the visit. Administrator agreed to not prepare resident's medications more than 24 hours in advance. POC cleared.
Type B
Section Cited
CCR
87458(c)(1)(A)
Medical Assessment
(c) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the licensed medical professional's diagnosis or diagnoses and results of an examination for all of the following: (A) Communicable tuberculosis.

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 aboveas two resident's medical assessments did not contain proof of a negative TB test which poses a potential health risk to persons in care.
POC Due Date: 03/05/2025
Plan of Correction
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Licensee will submit proof of negative TB tests for the identified residents 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.
SUPERVISOR'S NAME:Kasandra Lopez
LICENSING EVALUATOR NAME:Trevor Byrne
LICENSING EVALUATOR SIGNATURE:
DATE: 02/19/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/19/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/19/2025 02:44 PM - It Cannot Be Edited


Created By: Trevor Byrne On 02/19/2025 at 01:45 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: MARY ELLEN HOMES
FACILITY NUMBER: 195850089

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/19/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87464(f)(1)
87464 Basic Services
(f) Basic services shall at a minimum include:
(1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code
section 1569.2(c).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above as one resident was observed to be absent from the facility while out on a walk without staff assistance while their medical assessment indicated that they are unable to leave the facility unassisted which poses a potential safety risk to persons in care.
POC Due Date: 03/05/2025
Plan of Correction
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Licensee will submit a statement of understanding to CCLD confirming that they understand the importance of following physician's orders and providing appropriate care and supervision to residents. Licensee may submit an updated medical assessment indicating that the resident is able to leave the facility unassisted. Licensee will submit documents no later than POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Kasandra Lopez
LICENSING EVALUATOR NAME:Trevor Byrne
LICENSING EVALUATOR SIGNATURE:
DATE: 02/19/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/19/2025


LIC809 (FAS) - (06/04)
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