195850128-3-27-2025-29-AS-CYEE-DF73SY-20250327183106

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 195850128
Report Date: 03/27/2025
Date Signed: 03/27/2025 06:31:20 PM

Document Has Been Signed on 03/27/2025 06:31 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:	NO HO RESIDENTIAL CARE, INC.		FACILITY NUMBER:	195850128
ADMINISTRATOR/ DIRECTOR:	DURGARYAN, REBEKA		FACILITY TYPE:	740
ADDRESS:	6605 AGNES AVENUE		TELEPHONE:	(818) 404-0290
CITY:	NORTH HOLLYWOOD	STATE: CA	ZIP CODE:	91606
CAPACITY: 6		CENSUS: 6	DATE:	03/27/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	10:24 AM
MET WITH:	Laura Hovhannisyan, Staff		TIME VISIT/ INSPECTION COMPLETED:	06:40 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	Licensing Program Analyst (LPA) Christine Yee conducted an unannounced required Annual Inspection using the complete CARE Inspection Tool and was let into the home by Naira Aghajanyan, Staff. Rebeka Durgaryan, Administrator was contacted by staff and LPA Yee was advised that Laura Hovhannisyan, Designated Responsible Staff would conduct today's visit since she was on vacation. A completed LIC308 - Designation of Facility Responsibility was observed in the staff's file. Ms. Hovhannisyan arrived a little later to conduct the visit. The reason for today's visit was provided. The home is a single storey family home consisting of 5 bedrooms, 3 full bathrooms of which one is designated for staff use, a living room, dining room, a den, office and a kitchen. All five bedrooms are now used by residents. The facility is fire cleared for 1 BEDRIDDEN and 5 NON-AMBULATORY residents. Bedroom #2, located in the back right hand corner, is designated for Bedridden use On today's visit, LPA Yee reviewed 6 resident files, 7 staff files, and completed the following 2 domains of the CARE Inspection Tool 1. Infection Control and Personnel Records/Staff Training. A quick tour of the 5 residents rooms was conducted to verify the use of each room due to changes observed from previous visits conducted to the facility. Bedroom #5, by the front door was formerly designated for Staff use was observed with 1 resident and Bedroom #4, directly by the dining room was formerly used for storage was observed with 1 resident in a hospital bed with full bed rails. Bedroom #3 has 2 beds with 2 residents, Bedroom #2 was observed with 2 beds and Bedroom #1 was observed with 2 beds and 1 resident. A total of 8 beds were observed and the facility is licensed for a capacity of 6. The facility may only have beds for the capacity CONTINUED ON LIC809-D

NAME OF LICENSING PROGRAM MANAGER: Kristin Heffernan
NAME OF LICENSING PROGRAM ANALYST: Christine Yee
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 03/27/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2025

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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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 N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: NO HO RESIDENTIAL CARE, INC.	FACILITY NUMBER: 195850128
	VISIT DATE: 03/27/2025

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for which it is approved. The Licensee needs to do the following:
Per file review, the facility does not have physicians orders on file for all centrally stored medications and needs to contact the prescribing physician to obtain copies of the Physician orders.
the facility needs to remove all full bed rails and half bed rails that are being utilized by residents that are on hospice but it is not included in their hospice care plan and half bed rails if there is no doctor's order for the use of the rails and provide evidence to the Department of removal.
the facility is providing quarterly simulated class room drills with all staff present during the morning shift but are not conducting unannounced simulated fire drills during different shifts.
the facility needs to update the facility sketch to include room numbers, location of shutoff valves and the meeting point in an emergency.
Resident #1 does not have a primary diagnosis noted on the Physician's report
Resident #4's Physician Report does not indicate if the resident is able to leave the facility unassisted.
The facility electrician was at the facility today to repair a smoke detector. During this visit, the hard wired smoke detectors in the all residents rooms, living room and the combination smoke/carbon monoxide detector located in the office and outside bedroom #3 were tested and were all operational.

Due to time constraints and issues with obtaining records a return visit is needed to complete the annual inspection. Any deficiencies not cited on today's visit will be cited on a return visit.

Exit interview was conducted.

NAME OF LICENSING PROGRAM MANAGER: Kristin Heffernan
NAME OF LICENSING PROGRAM ANALYST: Christine Yee
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 03/27/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2025

LIC809 (FAS) - (06/04)

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