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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195850179
Report Date: 07/19/2024
Date Signed: 07/19/2024 06:04:56 PM

Document Has Been Signed on 07/19/2024 06:04 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:YMZ ASSISTED LIVINGFACILITY NUMBER:
195850179
ADMINISTRATOR/
DIRECTOR:		DURGARYAN, REBEKAFACILITY TYPE:
740
ADDRESS:6206 KLUMP AVENUETELEPHONE:
(818) 358-2955
CITY:NORTH HOLLYWOODSTATE: CAZIP CODE:
91606
CAPACITY: 6CENSUS: 6DATE:
07/19/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:29 AM
MET WITH:Rebeka Durgaryan, AdministratorTIME VISIT/
INSPECTION COMPLETED:
06:10 PM
NARRATIVE
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Licensing Program Analyst(LPA) Christine Yee conducted an unannounced required Annual Inspection using the complete CARE Inspection Tool. LPA Yee was let into the home by Naira Aghajanyan, Staff. Staff contacted the Administrator via telephone and she arrived at 11:14am to conduct the visit. The reason for today's visit was provided.

The facility is a single storey home consisting of a living room, dining room, kitchen, 3 bedrooms and 2 full bathrooms and a fenced in swimming pool. Located in the back of property is a separate 2 storey building. The facility has a fire clearance for 5 NON-AMBULATORY and 1 BEDRIDDEN residents. Bedroom #1 is the approved room for bedridden use.

The following domains were reviewed on today's visit: Infection Control, Physical Plant and Environmental Safety, Residents Rights-Information, Food Service, Disaster Preparedness (partial). 7 staff files and 6 resident files were reviewed. Due to time constraints the remaining domains will be reviewed on a return visit.

On today's visit, the following were observed:
  • The living room, dining room and kitchen had the appropriate furnishings.
  • Sufficient perishable foods and sufficient non-perishable foods were observed
  • The common bathroom was observed with grab bars and a non-skid mat. The water temperature was tested and it read 117.1 degrees Fahrenheit.
  • The water temperature was tested in the private bathroom and the it read 121.4 degrees Fahrenheit.
  • The hardwired smoke/carbon monoxide detector and smoke detectors were tested and were operational.
  • The cleaning solutions are stored in a locked cabinet under the kitchen sink
  • Medications are stored in a locked cabinet located in the dining room
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Christine Yee
LICENSING EVALUATOR SIGNATURE: DATE: 07/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/19/2024
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 4
Document Has Been Signed on 07/19/2024 06:04 PM - It Cannot Be Edited


Created By: Christine Yee On 07/19/2024 at 05:03 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: YMZ ASSISTED LIVING
FACILITY NUMBER: 195850179

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/19/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

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 in 1 count out of 2 bathroom where the water temperature was tested, the water temperature tested in the private bathroom tested 121.4 degrees Fahrenheit which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/20/2024
Plan of Correction
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The Licensee will adjust the water heater thermostat and re-test the water in the private bathroom to ensure that the water temperature reads 105 - 120 degrees Fahrenheit as required by Title 22 The Licensee will fax over a self certification that the water temperature meets Title 22 requirements by 7/20/24
Type A
Section Cited
CCR
87309(a)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

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 per observation of items stored in the cabinet of the private bathroom in bedroom #2 was a can of Lysol and cleaning solution and a can of lighter fluid was observed left on the barbecue grill located by the swimming pool which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/20/2024
Plan of Correction
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Licensee will ensure that all disinfectants, cleaning solutions, fire arms and other items which could pose a danger to the residents in care are stored when it is inaccessible to the residents. LIcnesee will remove the items noted and place them in a place where it is inaccessible to the residents by 7/20/24
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:Kristin Heffernan
LICENSING EVALUATOR NAME:Christine Yee
LICENSING EVALUATOR SIGNATURE:
DATE: 07/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/19/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/19/2024 06:04 PM - It Cannot Be Edited


Created By: Christine Yee On 07/19/2024 at 05:25 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: YMZ ASSISTED LIVING
FACILITY NUMBER: 195850179

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/19/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(e)(4)
e) Water supplies and plumbing fixtures shall be maintained as follows: (e) Water supplies and plumbing fixtures shall be maintained as follows: (4) Grab bars shall be maintained for each toilet, bathtub and shower used by residents.

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 it was observed that the shower stall and toilet in the private bathroom did not have grab bars installed which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/26/2024
Plan of Correction
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Licensee will install a grab bar in the shower stall and toilet located in the private bathroom in bedroom #2
Type B
Section Cited
CCR
87303(a)
87303 Maintenance and Operation: (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors

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 the blinds on the front window in bedroom #3 were broken which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/26/2024
Plan of Correction
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Licensee will replace the blinds on the front window located in bedroom #3. Evidence of the repair will be faxed over to the Department by 7/26/24.
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:Kristin Heffernan
LICENSING EVALUATOR NAME:Christine Yee
LICENSING EVALUATOR SIGNATURE:
DATE: 07/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/19/2024


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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: YMZ ASSISTED LIVING
FACILITY NUMBER: 195850179
VISIT DATE: 07/19/2024
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  • knives are locked in a kitchen drawer.
  • trash cans were observed with tightly sealed lids.
  • The facility was observed to be clean, inside and outside
  • The pool was observed enclosed with a rod iron fence and was locked.

Any deficiencies not cited on today's visit will be addressed on a return visit.

Exit interview was conducted with Ada Bozkurt, a Copy of the appeals rights was provided
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Christine Yee
LICENSING EVALUATOR SIGNATURE:

DATE: 07/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2024
LIC809 (FAS) - (06/04)
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