195850146-5-1-2025-29-AS-ABAN-DG9TX8-20250501150644

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 195850146
Report Date: 05/01/2025
Date Signed: 05/01/2025 03:07:50 PM

Document Has Been Signed on 05/01/2025 03:07 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:	MY HOME OF AGING		FACILITY NUMBER:	195850146
ADMINISTRATOR/ DIRECTOR:	KYKHOSROWPOUR, VISHTASB		FACILITY TYPE:	740
ADDRESS:	23817 BESSEMER STREET		TELEPHONE:	(818) 433-4592
CITY:	WOODLAND HILLS	STATE: CA	ZIP CODE:	91367
CAPACITY: 6		CENSUS: 5	DATE:	05/01/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:56 AM
MET WITH:	Vishtasb Kykhosrowpour and Farnaz Servati		TIME VISIT/ INSPECTION COMPLETED:	03:15 PM

NARRATIVE

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Licensing Program Analyst (LPA) Angela Barutyan arrived at the facility unannounced to conduct a required annual visit at 09:56AM. Upon arrival, LPA met with staff and House Manager Farnaz Servati who arrived at 10:02AM and Administrator Vishtasb Kykhosrowpour who arrived at 10:17AM. Entrance interview conducted.

At 10:03AM, the LPA along with the House Manager, toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations.

KITCHEN: The LPA inspected the kitchen/food service area at 10:03AM. Kitchen appliances appeared clean and were in operable condition at the time of the visit. The facility has a sufficient supply of perishable and nonperishable food. Food labels were inspected and checked for expiration dates and food labels had expiration date clearly marked. Knives and chemicals were locked inaccessible in kitchen drawer and under-the-sink cabinet.

BEDROOMS: There are six (6) private resident bedrooms. Bedroom #1 has a direct exit to the exterior. LPA observed resident bedrooms to be furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting.

RESTROOMS: There are four (4) restrooms designated for resident-use of which two (2) restrooms are attached to resident bedrooms and two (2) are located in the hallway. Restrooms were clean and sanitary and in operating condition with grab bars and slip-resistant surfaces. The restrooms were sufficiently stocked with supplies and paper towels; towels and washcloths are not shared. Hot water temperature was measured in three (3) bathrooms and measured between 115.4-119.2 degrees Fahrenheit, which is within the required range. Report Continued on LIC 809-C

NAME OF LICENSING PROGRAM MANAGER: Kristin Heffernan
NAME OF LICENSING PROGRAM ANALYST: Angela Barutyan
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/01/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2025

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: MY HOME OF AGING	FACILITY NUMBER: 195850146
	VISIT DATE: 05/01/2025

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COMMON AREAS: The common spaces included the living room, dining area, and office area. LPA observed cameras in all common spaces and exterior without an audio component. All areas were clean, sanitary and in good repair. The facility smoke alarm system is hard wired; the combination smoke and carbon monoxide detectors were tested at 10:19AM and were operable at the time of the visit. The fire extinguisher was observed be fully charged and last purchased 04/25/2025. Auditory exit alarms were tested and functional at the time of the visit. LPA observed required postings in the entrance hallway.

OUTDOOR AREA/GARAGE: The backyard has a covered outdoor area equipped with furniture for resident use. There is a pool on the property that was observed to be gated and locked at the time of the visit. There is a self-latching gate on the side of the house designated for an emergency exit. Passageways were free and clear from obstruction. LPA observed a laundry room which is located inside the attached garage. Laundry detergents, additional refrigerator/freezer, cleaning supplies, pesticides, and/or toxins are also stored in the garage/laundry area.

RECORD REVIEW: Beginning at 10:38AM, LPA reviewed five (5) out of five (5) resident files and four (4) out of four (4) personnel files for documents including but not limited to: medical records, care plans, resident Admission Agreement, TB test, health screening, staff training, first aid certification, and fingerprint clearance. All resident files were in order. One (1) out of four (4) staff was missing first aid training; training was completed during the visit.

MEDICATION REVIEW: At 02:20PM, LPA reviewed medications for two (2) residents. Medications are centrally stored and locked in the garage. All medications including PRNs were labeled, stored, and locked inaccessible to residents. PRNs have physicians order and authorization letter on file. Medications are properly documented on the centrally stored medications and destruction record. One (1) medication of Metoprolol was expired on 04/28/2025. House Manager will destroy the medication. No errors observed during the medication review. INFECTION CONTROL/EMERGENCY DISASTER PLANNING: During today’s visit, the LPA reviewed the facility's infection control policy and emergency disaster plan. Emergency disaster plan is updated annually as required and emergency disaster drills are conducted quarterly as is required, with the last drill conducted on 03/26/2025. All documents reviewed were updated and in compliance.

The following deficiency was observed (See LIC 809-D) and cited from the California Code of Regulations, Title 22. Administrator was informed that failure to correct deficiency may result in civil penalties.

Exit interview was conducted. A copy of the report and appeal rights were provided.

NAME OF LICENSING PROGRAM MANAGER: Kristin Heffernan
NAME OF LICENSING PROGRAM ANALYST: Angela Barutyan
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/01/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 05/01/2025 03:07 PM - It Cannot Be Edited

Created By: Angela Barutyan On 05/01/2025 at 02:53 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: MY HOME OF AGING	FACILITY NUMBER: 195850146
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/01/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87411(c)(1)

Personnel Requirements - General

(1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review and interview, the licensee did not comply with the section cited above as one (1) out of four (4) staff did not have first aid training which posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/08/2025
	Plan of Correction
1 2 3 4	The staff member completed first aid training and provided valid certification during the visit. POC is cleared.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Kristin Heffernan
NAME OF LICENSING PROGRAM MANAGER:

	Angela Barutyan
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/01/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2025

LIC809 (FAS) - (06/04)

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