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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195850207
Report Date: 01/14/2026
Date Signed: 01/14/2026 07:10:02 PM

Document Has Been Signed on 01/14/2026 07:10 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: 5DATE:
01/14/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:48 AM
MET WITH:Mary Petikyan, AdministratorTIME VISIT/
INSPECTION COMPLETED:
07:15 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 11:16 a.m. 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 12 domains of the Inspection Care Tool were reviewed, 5 residents and 8 staff files were reviewed on today's visit and the following were 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 3/25/25. The second fire extinguisher is located in the family room and was also purchased on 3/25/25.
  • The office was observed with a table, 4 chairs, a bench, a 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


continued on LIC809-C
NAME OF LICENSING PROGRAM MANAGER: Kristin Heffernan
NAME OF LICENSING PROGRAM ANALYST: Christine Yee
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 01/14/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/14/2026
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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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: 01/14/2026
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  • 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. The auditory device on the outside exiting door to the back yard was operational.
  • 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. The auditory device in bedroom #1 was operational.
  • 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 117.3 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 118.6 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 114.0 degrees Fahrenheit.
  • The first aid kit was observed with bandages, gauze and the required tweezer, scissor and an external thermometer. A first aid manual was observed.
  • The facility has current general liability insurance that meets Title 22 requirements.


continued on LIC809-C
NAME OF LICENSING PROGRAM MANAGER: Kristin Heffernan
NAME OF LICENSING PROGRAM ANALYST: Christine Yee
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 01/14/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/14/2026
LIC809 (FAS) - (06/04)
Page: 3 of 4
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: 01/14/2026
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  • The hardwired smoke detectors in the bedrooms and the combination smoke/carbon monoxide detectors located in the office, living room, the hallway of the front resident rooms and in the 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.
NAME OF LICENSING PROGRAM MANAGER: Kristin Heffernan
NAME OF LICENSING PROGRAM ANALYST: Christine Yee
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 01/14/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/14/2026
LIC809 (FAS) - (06/04)
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