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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195850178
Report Date: 10/03/2024
Date Signed: 10/03/2024 03:54:17 PM

Document Has Been Signed on 10/03/2024 03:54 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:MONOGRAM VILLAFACILITY NUMBER:
195850178
ADMINISTRATOR/
DIRECTOR:		KRBASHYAN, AZNIV ANGELAFACILITY TYPE:
740
ADDRESS:5536 TYRONE AVETELEPHONE:
(818) 808-7792
CITY:SHERMAN OAKSSTATE: CAZIP CODE:
91401
CAPACITY: 6CENSUS: 6DATE:
10/03/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:00 AM
MET WITH: AZNIV ANGELA KRBASHYAN, ADMINISTRATORTIME VISIT/
INSPECTION COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Erica Mosley arrived at the facility at approx.11:15 am to conduct an unannounced required annual visit. Upon arrival, LPA Mosley was greeted by staff and called the administrator to inform them of the visit. The administrator arrived shortly thereafter. The LPA met with Administrator AZNIV ANGELA KRBASHYAN 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 facility is in compliance with Title 22 Regulations.
Licensee is in the process of getting an increase in capacity to 12 and has already submitted information to the department for approval.
LPA arrived and observed all six (6) residents eating lunch together followed by group discussion. Food menu matched the food that was served.

BEDROOMS: The facility is a single-story residential home with nine (9) bedrooms, six (6) for resident's use and three (3) for staff. The LPA observed resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting. Inside temperature was maintained at a comfortable level.



RESTROOMS: The facility has eight (8) restrooms, six (6) for resident use and two (2) for staff/ public use. Restrooms clean and sanitary and in operating condition with grab bars and non-skid mats. Starting at approx. 11:39 a.m., hot water measured between 105.7 and 112.6-degree Fahrenheit. The sinks had sufficient liquid soap, and paper towels.
Continued on LIC 809-C.
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Erica Mosley
LICENSING EVALUATOR SIGNATURE: DATE: 10/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/03/2024
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: MONOGRAM VILLA
FACILITY NUMBER: 195850178
VISIT DATE: 10/03/2024
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Report Continued from LIC 809C...

KITCHEN: At approx. 11:48am the LPA observed the kitchen/dining area. Knives are stored in a locked kitchen drawer. Kitchen appliances are in operable condition. The facility has a sufficient supply of two (2) day perishable and seven (7) day non-perishable food. Refrigerators and food pantry were checked for proper labels and expiration dates. One (1) refrigerator is for staff use, one (1) is for facility use and a beverage refrigerator. The staff refrigerator has a locked medication box if needed, however it currently is not in use. Hot water measured at 105.1-degree Fahrenheit. Medications and first aid kits are in a locked cabinets near the kitchen area. First Aid supplies were checked at 11:55am, all supplies in order. Cleaning solutions, toxins, chemicals, and hazardous items were inaccessible and locked away in a cabinet near the kitchen area. The laundry units are located near the kitchen area. Emergency supplies including food and water are stored in one of the kitchen cabinets.

COMMON AREAS: The LPA observed the common area to be clean and properly furnished. The LPA observed the fire extinguisher to be fully charged and last serviced on 04/26/2024. At 1:56 p.m., fire alarms/ carbon monoxide detectors were tested and functioned properly. Night lights were present in the hallway. The LPA observed an activities area near the dining room for resident use. The LPA observed required postings throughout the common space. The last emergency disaster drill took place on 6/15/24 and are conducted quarterly. Activities were observed in the common areas.


OUTDOOR SPACE: At 12:12 p.m., the LPA observed the back patio and side patio which has a covered patio area with patio furniture including a table and chairs for resident use. The gates on the side and back of the house are self-latching and designated as emergency exits. All passageways were observed to be clear. There are three (3) storage units supplying extra bedding and nonchemical supplies. One (1) outdoor freezer with food for daily use. There are no bodies of water on the premises at the time of the visit.

Continued on LIC 809-C.

SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Erica Mosley
LICENSING EVALUATOR SIGNATURE:

DATE: 10/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2024
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: MONOGRAM VILLA
FACILITY NUMBER: 195850178
VISIT DATE: 10/03/2024
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Report Continued from LIC 809C...


RECORDS: Resident Records were reviewed beginning at 12:19 p.m. and personnel records at 1:00 p.m. Six (6) resident files were reviewed for, but not limited to, the following: signed admission agreements, current medical assessments with TB results, LIC627(c) Consent for Treatment form, and current needs and services plan. Five (5) personnel files including the Administrator’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 records were in order.

INTERVIEWS: Two (2) staff interviews were conducted. Six (6) client interviews were attempted, two (2) client interviews conducted and one (1) visitor / family member of a resident was interviewed during the inspection.

MEDICATIONS: Medications review began at approximately 2:25 pm. The medications are locked in a cabinet in the kitchen. Medications for six clients were reviewed. Medications reviewed were found to be self-administered as prescribed and documented on the centrally stored medication and destruction records.

No deficiencies were cited during today’s inspection. Exit interview conducted. A copy of the report was provided.

SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Erica Mosley
LICENSING EVALUATOR SIGNATURE:

DATE: 10/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2024
LIC809 (FAS) - (06/04)
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