<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195850179
Report Date: 07/23/2025
Date Signed: 07/23/2025 05:20:41 PM

Document Has Been Signed on 07/23/2025 05:20 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: 5DATE:
07/23/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:02 AM
MET WITH:Rebeka Durgaryan - LicenseeTIME VISIT/
INSPECTION COMPLETED:
05:30 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 9:02AM. The LPA met with Staff #1 (S1), explained the reason for the visit, and they notified the Licensee. The Licensee Rebeka Durgaryan arrived at 9:35AM. Entrance interview conducted.

Beginning at 9:14AM, the LPA and S1 toured the physical plant areas inside and outside to ensure there are no health and safety hazards, and the facility is in compliance with Title 22 Regulations. The facility is a single-story residential home. The following was observed:

COMMON AREAS: At the time of the visit, living room and dining room furniture was observed to be in good condition. The living room had a screened fireplace that was inoperable. Required postings were observed in the living room. Locked file cabinets were observed near the dining table and contained files and medications. The facility maintained a comfortable temperature throughout the visit. There was a laundry room located in the hallway of the rear exit. Laundry machines were observed to be operational and locked cabinets contained detergent and cleaning supplies.

BEDROOMS/RESTROOMS: There were three (3) total bedrooms, each with dual occupancy. Bedrooms #1 and #2 had direct exits to the outside, with Bedroom #1 approved for one (1) bedridden resident.

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: 07/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/23/2025
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 11
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)
Page: 2 of 11
Document Has Been Signed on 07/23/2025 05:20 PM - It Cannot Be Edited


Created By: Quoc Huynh On 07/23/2025 at 04:19 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: 07/23/2025

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: (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
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in the resident's restroom sink delivered water at 149 degrees F which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/24/2025
Plan of Correction
1
2
3
4
The Licensee will call a technician to check and adjust the water heater and send CCLD proof of water temperature within the required range by POC due date.
Type A
Section Cited
CCR
87204(a)
Limitations -Capacity and Ambulatory Status
(a) A licensee shall not operate a facility beyond the conditions and limitations specified on the license, including specification of the maximum number of persons who may receive services at any one time. An exception may be made in the case of catastrophic emergency when the licensing agency may make temporary exceptions to the approved capacity.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on interview, the licensee did not comply with the section cited above in 1 Staff lives on the premises and sleeps on the living room futon which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/24/2025
Plan of Correction
1
2
3
4
The Licensee will create a written plan to address the living arrangements of the Staff and how they will enforce it. The Licensee will send CCLD the plan by POC due date.
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: 07/23/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/23/2025


LIC809 (FAS) - (06/04)
Page: 3 of 11
Document Has Been Signed on 07/23/2025 05:20 PM - It Cannot Be Edited


Created By: Quoc Huynh On 07/23/2025 at 04:19 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: 07/23/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87307(d)(2)
Personal Accommodations and Services
(2) The premises shall be maintained in a state of good repair and shall provide a safe and healthful environment.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above. The facility's side yard has exposed electrical wiring and a hole in the wooden ramp utilized by residents which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/24/2025
Plan of Correction
1
2
3
4
The Licensee secured the electrical wiring during the visit. The Licensee will contact a technician and schedule an appointment to repair the wooden ramp and notify CCLD of the appointment date. The Licensee will then send proof of the repair after it has been completed.
Type A
Section Cited
CCR
87307(d)(6)
Personal Accommodations and Services
(6) All outdoor and indoor passageways and stairways shall be kept free of obstruction.

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 1 bed frame was obstructing the passageway of the emergency side exit which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/24/2025
Plan of Correction
1
2
3
4
The Licensee will discard of the bed frame or relocate the bed frame where it is not a hazard or obstructing any passageways. The Licensee will send proof to CCLD by POC due date.
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: 07/23/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/23/2025


LIC809 (FAS) - (06/04)
Page: 4 of 11
Document Has Been Signed on 07/23/2025 05:20 PM - It Cannot Be Edited


Created By: Quoc Huynh On 07/23/2025 at 04:19 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: 07/23/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87307(e)(2)(A)
Personal Accommodations and Services
(e) The licensee shall supervise residents as needed and as determined by the resident's appraisal pursuant to Section 87457, Pre-Admission Appraisal or Section 87463, Reappraisals, when residents are in proximity to or when there is use of the following items: (2) Fishponds, wading pools, hot tubs, swimming pools, or similar larger bodies of water. (A) The licensee shall ensure that the bodies of water specified above are inaccessible through fencing, covering, or other means when not in active use by residents.

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 2 out of 2 pool gates were unsecured which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/23/2025
Plan of Correction
1
2
3
4
The Licensee secured the pool gate and reinstalled the side gate during the visit. POC Cleared.
Type A
Section Cited
CCR
87309(a)
Storage Space and Access
(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage.

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 1 restroom cabinet containing cleaning supplies was unlocked which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/23/2025
Plan of Correction
1
2
3
4
Staff secured and locked the restroom cabinet during the visit. POC Cleared.
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: 07/23/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/23/2025


LIC809 (FAS) - (06/04)
Page: 5 of 11
Document Has Been Signed on 07/23/2025 05:20 PM - It Cannot Be Edited


Created By: Quoc Huynh On 07/23/2025 at 04:19 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: 07/23/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(a)(5)(D)
Incidental Medical and Dental Care Services
(5) Facility staff, except those authorized by law, shall not administer injections, but staff designated by the licensee may assist persons with self-administration as needed. Assistance with self-administered medications shall be limited to the following: (D) Assistance with self-administration does not include forcing a resident to take medications, hiding or camouflaging medications in other substances without the resident's knowledge and consent, or otherwise infringing upon a resident's right to refuse to take a medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on interview and record review, the licensee did not comply with the section cited above. The facility's Staff crushes 1 resident's medications without a physician's order which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/24/2025
Plan of Correction
1
2
3
4
The Licensee will contact the Physician and obtain the crush order. The Licensee will send CCLD the Physician's crush order 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: 07/23/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/23/2025


LIC809 (FAS) - (06/04)
Page: 6 of 11
Document Has Been Signed on 07/23/2025 05:20 PM - It Cannot Be Edited


Created By: Quoc Huynh On 07/23/2025 at 04:19 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: 07/23/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
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
1
2
3
4
Based on observation and interview, the licensee did not comply with the section cited above in 1 kitchen drawer's face panel was falling off the screws and 1 fire door latch was jammed which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/24/2025
Plan of Correction
1
2
3
4
The Licensee will have a technician repair the kitchen drawer and send CCLD proof by POC due date. The Licensee repaired the fire door latch during the visit.
Type B
Section Cited
CCR
87465(e)
Incidental Medical and Dental Care Services
(e) For every prescription and nonprescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician on a prescription blank, maintained in the resident's file, and a label on the medication. Both the physician's order and the label shall contain at least all of the following information.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on interview and record review, the licensee did not comply with the section cited above in 2 out of 2 residents receiving PRN Medications do not have a PRN Authorization Letter or PRN administration log which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/30/2025
Plan of Correction
1
2
3
4
The Licensee will obtain PRN Authorization Letters and send CCLD the letters by POC due date. The Licensee will update Staff training and submit a statement of understanding on recording PRN medications and send it to CCLD by POC due date.
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: 07/23/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/23/2025


LIC809 (FAS) - (06/04)
Page: 7 of 11
Document Has Been Signed on 07/23/2025 05:20 PM - It Cannot Be Edited


Created By: Quoc Huynh On 07/23/2025 at 04:19 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: 07/23/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(a)(2)
Other Provisions
(a)In addition to any other requirement of this chapter, a residential care facility for the elderly shall have an emergency and disaster plan that shall include, but not be limited to, all of the following: (2) Plans for the facility to be self-reliant for a period of not less than 72 hours immediately following any emergency or disaster, including, but not limited to, a short-term or long-term power failure. If the facility plans to shelter in place and one or more utilities, including water, sewer, gas, or electricity, is not available, the facility shall have a plan and supplies available to provide alternative resources during an outage.

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. The facility did not have emergency water which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/23/2025
Plan of Correction
1
2
3
4
The Licensee purchased emergency water during the visit. POC 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:
Quoc Huynh
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/23/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/23/2025


LIC809 (FAS) - (06/04)
Page: 8 of 11
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: 07/23/2025
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
26
27
28
29
30
31
32
Bedrooms were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. Extra linens were stored in the hallway cabinet. There were two (2) total restrooms in the facility: one (1) private restroom attached to Bedroom #2 that is utilized by Staff and one (1) shared resident restroom located in the hallway. 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. LPA observed an unlocked cabinet in the resident restroom that contained cleaning supplies. The Staff stated they forgot to lock it and was planning on cleaning when the LPA arrived. The Staff immediately secured the cabinet. Hot water was tested in the resident restroom and measured at 149 degrees F which is not within the required range of 105 degrees F and 120 degrees F.

KITCHEN: The LPA observed knives stored inaccessible in a locked drawer and the drawer’s front panel was falling off its screws. The Staff stated they did not notice the condition of the drawer. Cleaning supplies were locked under the kitchen sink. Kitchen appliances were clean and in operable condition. The facility had a supply of perishable and non-perishable food, as well as emergency food. Emergency water was not observed and the Licensee stated they did not have any. The Staff and Licensee stated the refrigerator in the Kitchen is broken and a new one will be arriving by 07/25/2025. Food is temporarily stored in the refrigerators and freezers in the rear patio which were observed to be properly stored with labels and dates.

OUTDOOR AREA: The rear of the facility had an Additional Dwelling Unit occupied by the Licensee. The LPA observed a fenced off pool, however, the gate was not secured. The gate was left ajar at a 40-degree angle and was observed to have a lock that was not in use. The Licensee stated the Staff must have forgotten to lock the pool gate and proceeded to lock the gate. The pool area had two (2) sheds that contained extra facility supplies and general storage. There was one (1) side gate that led to the front yard and was an emergency exit for Bedroom #2. The pool area was also accessible through the side yard and the Licensee stated they removed the gate that separated the pool area from the side yard as a Plan of Corrections on a prior visit.

Report Continued on LIC 809-D
NAME OF LICENSING PROGRAM MANAGER: Kristin Heffernan
NAME OF LICENSING PROGRAM ANALYST: Quoc Huynh
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/23/2025
LIC809 (FAS) - (06/04)
Page: 9 of 11
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: 07/23/2025
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
26
27
28
29
30
31
32
Prior citation in regard to securing the pool was not found. The Licensee stated they will re-install the gate. The LPA also observed exposed electrical wires along the side yard’s wall and a hole on the wooden ramp utilized by Bedroom #2. The surrounding rear had one (1) shaded patio area equipped with furniture in good condition for resident and visitor use. The front yard had a driveway with an operated gate as well as a door for everyday use. The opposite side of the property had a driveway used as an emergency exit that also led to the front yard. The LPA observed a brown bed frame in the front yard, obstructing the side exit. The Licensee stated it was a brand-new bed that they were planning to replace for a resident; however, the bed was broken.

RECORDS: Record review began at 9:56AM. Resident records were reviewed for, but not limited to care plans, physician's report, 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. Records were in order with Staff training missing 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 reviewed annually as required. Emergency disaster drills are conducted quarterly, with the last documented drill on 04/10/2025. Smoke and carbon monoxide detectors as well as the fire door were tested at 9:47AM. The fire door did not latch when released, and was observed to be stuck inside the mechanism. The Licensee stated that smoke alarms were recently replaced and tested, and they did not have this issue. The Licensee called a technician out to the facility, and fixed the latch.

MEDICATIONS: Medication review began at 2:21PM. Medications were centrally stored and kept inaccessible. Medications were observed for three (3) residents. Medications were labeled and checked for expiration dates and were properly documented on the centrally stored medications and destruction record.

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: 07/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/23/2025
LIC809 (FAS) - (06/04)
Page: 10 of 11
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: 07/23/2025
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
26
27
28
29
30
31
32
Resident #1 (R1) and Resident #2 (R2) were prescribed PRN (as needed) medications and the Licensee did not have a PRN Authorization Letter on file, or records of when and why the PRN medication was administered. Additionally, interview with S1 and the Licensee revealed that they crush Resident #3’s (R3) medications and put it in R3’s food because R3 has trouble swallowing. The Licensee did not have orders from a physician to crush R3’s medications and stated when R3 was previously on Hospice, that was the orders, but R3 is no longer on Hospice.

Three (3) Staff and four (4) residents were interviewed.

Pursuant to Title 22 CA Code of Regulations and/or Health and Safety Code, the following deficiencies were cited (Refer to LIC 809-D).

Exit interview conducted. A copy of the report and appeal rights were reviewed and provided.
NAME OF LICENSING PROGRAM MANAGER: Kristin Heffernan
NAME OF LICENSING PROGRAM ANALYST: Quoc Huynh
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/23/2025
LIC809 (FAS) - (06/04)
Page: 11 of 11