195850178-9-4-2025-29-AS-QHUH-DL7RCG-20250904125419

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 195850178
Report Date: 09/04/2025
Date Signed: 09/04/2025 12:54:36 PM

Document Has Been Signed on 09/04/2025 12:54 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 VILLA		FACILITY NUMBER:	195850178
ADMINISTRATOR/ DIRECTOR:	KRBASHYAN, AZNIV ANGELA		FACILITY TYPE:	740
ADDRESS:	5536 TYRONE AVE		TELEPHONE:	(818) 808-7792
CITY:	SHERMAN OAKS	STATE: CA	ZIP CODE:	91401
CAPACITY: 6		CENSUS: 5	DATE:	09/04/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:35 AM
MET WITH:	Angela Krbashyan - Licensee		TIME VISIT/ INSPECTION COMPLETED:	01:00 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) Quoc Huynh arrived at the facility unannounced to conduct a required annual visit at 9:35AM. The LPA was greeted by Staff, informed them of the reason for the visit, and staff proceeded to notify the Licensee. The Licensee Angela Krbashyan arrived shortly thereafter. Entrance interview conducted. Beginning at 9:52AM, the LPA and Licensee toured the physical plant areas inside and outside to ensure there were no health and safety hazards, and the facility is in compliance with Title 22 Regulations. The following was observed: KITCHEN: Knives were stored inaccessible in a locked drawer near the sink. Cleaning supplies, medications, and first aid kit were stored inaccessible and locked in cabinets to the right of the kitchen. Kitchen appliances were clean and in operable condition. The facility had a supply of perishable and non-perishable food, as well as emergency food and water within regulation. The LPA observed four (4) non-perishable food cans to be expired between May 2025 and August 2025. The Licensee stated the facility will review and update the non-perishables. Food in the two (2) refrigerators and freezers were observed to be properly stored. The kitchen contained laundry machines that were operational. Report Continued on LIC 809-C

NAME OF LICENSING PROGRAM MANAGER: Kristin Heffernan
NAME OF LICENSING PROGRAM ANALYST: Quoc Huynh
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 09/04/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/04/2025

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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Document Has Been Signed on 09/04/2025 12:54 PM - It Cannot Be Edited

Created By: Quoc Huynh On 09/04/2025 at 12:34 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: MONOGRAM VILLA	FACILITY NUMBER: 195850178
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/04/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87555(b)(28)

General Food Service Requirements

(b) The following food service requirements shall apply: (28) All food shall be protected against contamination. Contaminated food shall be discarded immediately upon discovery. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interview, the licensee did not comply with the section cited above in non-perishable food cans were expired which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/05/2025
	Plan of Correction
1 2 3 4	The Licensee discarded of expired non-perishables during the visit and will review and update the remainder of the food and send CCLD a statement of understanding regarding maintaining the facility's food supply by POC due date.

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:

	Quoc Huynh
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/04/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/04/2025

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: 09/04/2025

NARRATIVE

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COMMON AREAS: At the time of the visit, the living room and dining room furniture was observed to be in good condition. Required postings were in the reception/office area located at the entrance of the facility. The facility maintained a comfortable temperature throughout the visit. Nightlights were observed throughout the facility and a hallway closet contained extra linens.

BEDROOMS/RESTROOMS: There were nine (9) total bedrooms: seven (7) private resident rooms, one (1) staff room, and one (1) room utilized as storage. Bedroom #2 had a direct exit to the outside and the facility was approved for six (6) bedridden residents. Bedrooms were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. There were eight (8) total restrooms: one (1) visitor restroom and seven (7) private resident restrooms. Restrooms were clean and sanitary and in operating condition with grab bars and non-slip surfaces. All restrooms were sufficiently stocked with soap, paper products, and displayed hand washing signs. Hot water was tested and measured between 115.7 degrees F and 118.6 degrees F, which was within the required range. At this time, the facility was in the process of making adjustments for a facility capacity increase request to twelve (12) residents.

OUTDOOR AREA: The surrounding grounds had two (2) shaded patio areas equipped with furniture and a grilling area in good condition for residents and visitor use. There were three (3) remote driveway gates used for emergency exits with two pathways on both sides of the house that lead to both yards/driveways. The side pathways had three (3) self-latching gates. No bodies of water noted, and exits are free of obstructions. The LPA observed three (3) sheds in the backyard that contained general storage of facility supplies.

Report Continued on LIC 809-C

NAME OF LICENSING PROGRAM MANAGER: Kristin Heffernan
NAME OF LICENSING PROGRAM ANALYST: Quoc Huynh
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 09/04/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/04/2025

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: 09/04/2025

NARRATIVE

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RECORDS: Record review began at 10:43AM. Resident records were reviewed for, but not limited to care plans, physician reports, admissions agreement, and consent forms. All records were in order. Personnel records were reviewed for, but not limited to health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. The LPA had a discussion with the Licensee to ensure staff are signing their training records to indicate they have received the required topics and hours.

INFECTION CONTROL/EMERGENCY DISASTER PLAN: During today's visit, LPA reviewed the facility's infection control plan and emergency disaster plan. Both documents were observed to be complete and updated annually as required. Emergency disaster drills are conducted quarterly, with the last documented drill on 09/03/2025. Smoke and carbon monoxide detectors were tested at 10:14AM and were operational at the time of the visit. Fire extinguishers were observed throughout the facility and were last serviced on 04/15/2025.

MEDICATIONS: Medication review began at 11:52AM. Medications are centrally stored and kept inaccessible in the kitchen cabinets. Medications were observed for two (2) residents. Medications were labeled and checked for expiration dates. Medications were properly documented on the centrally stored medications and destruction record. No errors observed during the medication review.

Pursuant to Title 22 CA Code of Regulations, the following deficiency was cited (Refer to LIC 809-D).

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

NAME OF LICENSING PROGRAM MANAGER: Kristin Heffernan
NAME OF LICENSING PROGRAM ANALYST: Quoc Huynh
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 09/04/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/04/2025

LIC809 (FAS) - (06/04)

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