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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195850207
Report Date: 01/22/2025
Date Signed: 01/22/2025 05:53:02 PM

Document Has Been Signed on 01/22/2025 05:53 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:MARY'S CHATEAU IIFACILITY NUMBER:
195850207
ADMINISTRATOR/
DIRECTOR:		PETIKYAN, MARYFACILITY TYPE:
740
ADDRESS:15215 VALERIO STREETTELEPHONE:
(323) 333-8105
CITY:VAN NUYSSTATE: CAZIP CODE:
91405
CAPACITY: 6CENSUS: 4DATE:
01/22/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:26 AM
MET WITH:Mary Petikyan, AdministratorTIME VISIT/
INSPECTION COMPLETED:
06:00 PM
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Licensing Program Analyst (LPA) Christine Yee conducted an unannounced required Annual Inspection and was let into the home by Seda Hovhannisyan, Staff. Mary Petikyan, Administrator was contacted by staff and she arrived at 10:44am to conduct the visit. The reason for today's visit was explained.

The facility is a single storey family home consisting of a living room, office, kitchen, dining room, family room, 5 bedrooms of which one is used as a staff room, 2 common bathrooms, 1 private bathroom and a detached garage located in the back of the property. The facility is fire cleared for 5 NON-AMBULATORY and 1 BEDRIDDEN residents. Bedroom #4 is approved for bedridden use.

All domains of the Inspection Care Tool were reviewed and following was observed:
  • The living room was furnish with the appropriate seating and coffee table. The fire place was observed with a secured with fire screen. Located in the living room is a fire extinguisher purchased on 7/12/24. The second fire extinguisher is located in the family room.
  • The office was observed with a table, 4 chairs, a bench printer and a file cabinet used to store the residents' medications.
  • The kitchen is equipped with a stove, refrigerator, microwave and a center island with bar stools. Perishable foods for a minimum of two days and non-perishable foods for a minimum of 7 days were observed. Adjacent to the kitchen is the breakfast nook furnished with a table and four chairs.
  • Located by the kitchen is the staff bedroom furnished with a bed and has a refrigerator with additional perishable foods.
  • Also located by the kitchen is the locked laundry closet that was observed with a washer and dryer and cleaning solutions on a shelf.
  • The family room is furnished with a sectional sofa cable of seating 6 residents and a television
  • The dining room was observed with a table and 4 chairs.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Christine Yee
LICENSING EVALUATOR SIGNATURE: DATE: 01/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/22/2025
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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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: MARY'S CHATEAU II
FACILITY NUMBER: 195850207
VISIT DATE: 01/22/2025
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  • Bedroom #1 and Bedroom #2 is each furnished with a hospital bed, a night stand, a lamp, a chair and a built in closet. Window dressings were in good condition.
  • Located by bedroom #1 is the linen closet containing towels, extra blankets and bath towels, hand towels and face clothes.
  • Bedroom #3 is furnished with a hospital bed, a night stand, a lamp, a chair and a built in closet. The second bed and the required furniture was not set up as it is offered as private bedroom. Bed was
  • observed stored in the detached garage.
  • Bedroom #4 is furnished with 2 hospital beds, 2 chairs, 2 night stands, a built in closet, 2 lamps and a shared dresser. The room has a sliding glass equipped with a auditory device. Located inside the room is a private bathroom equipped with a shower, a toilet and a single sink. Grab bars and a non-skid mat was observed. Water temperature was tested and it read 116.2 degrees Fahrenheit.
  • The common bathroom located in the front was equipped with a shower, a toilet and a single sink. Grab bars and non-skid mats were observed. The water temperature was tested and read 116.2 degrees Fahrenheit.
  • The common bathroom located by the family room is equipped with a single sink, a toilet and a shower. Grab bars and non-skid mat was observed. The water temperature was tested and read 116.8 degrees Fahrenheit.
  • The first aid kit was observed with bandages, gauze and the required tweezer, scissor and an external thermometer.
  • The facility has current liability insurance that meets Title 22 requirements.
  • The hardwired combination smoke/carbon monoxide detectors located in all the residents bedrooms, hallway, living room, office, family room were tested and were operational.
  • Trash cans were observed to be tightly sealed
  • Per tour of the backyard, an umbrella for shade and a table with chairs were observed. The backyard and front yard were observed to be well maintained.


No deficiencies were cited on today's visit.

Exit interview was conducted and a copy of the report was provided.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Christine Yee
LICENSING EVALUATOR SIGNATURE:

DATE: 01/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/22/2025
LIC809 (FAS) - (06/04)
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