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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195850216
Report Date: 02/18/2025
Date Signed: 02/18/2025 05:10:27 PM

Document Has Been Signed on 02/18/2025 05:10 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:ELDERCARE HOMES, INC.FACILITY NUMBER:
195850216
ADMINISTRATOR/
DIRECTOR:		HEKIMYAN, LUIZAFACILITY TYPE:
740
ADDRESS:7754 COLDWATER CANYON AVENUETELEPHONE:
(818) 764-8545
CITY:N. HOLLYWOODSTATE: CAZIP CODE:
91605
CAPACITY: 6CENSUS: 4DATE:
02/18/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:50 AM
MET WITH:Tina ArutyunyanTIME VISIT/
INSPECTION COMPLETED:
05:15 PM
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Licensing Program Analyst (LPA) Trevor Byrne arrived at the facility unannounced to conduct a required annual visit at 10:50 AM. LPA met with facility staff who contacted the facility backup Administrator Tina Arutyunyan. The backup Administrator arrived to the facility at 11:40 AM. Entrance interview conducted and the reason for the visit was explained.

Beginning at 10:52 AM, the LPA, along with facility staff toured the physical plant areas inside and outside to ensure there are no health and safety hazards and that facility is in compliance with Title 22 Regulations. The following was observed:

KITCHEN: The LPA observed the kitchen area to be clean. Kitchen appliances appeared to be in operable condition. The facility has a sufficient supply of two (2) days perishable and seven (7) days non-perishable food. LPA observed a secured drawer to contain knives and other sharp objects. LPA observed a secured cabinet to contain resident medications. LPA observed a properly secured under-sink cabinet to contain cleaning supplies. LPA observed the laundry closet located adjacent to the kitchen. The laundry closet contained a washer and dryer and properly secured cabinets containing laundry chemicals. LPA observed a fire extinguisher mounted in the kitchen to be fully charged and purchased on 09/24/2024.

Continued on LIC 809C.
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Trevor Byrne
LICENSING EVALUATOR SIGNATURE: DATE: 02/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/18/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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: ELDERCARE HOMES, INC.
FACILITY NUMBER: 195850216
VISIT DATE: 02/18/2025
NARRATIVE
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COMMON AREAS: This includes the dining area, living room, hallway, office. LPA observed the dining area to be clean and properly furnished at the time of the visit. The dining area contains a dining table with adequate seating for resident use. The living room was observed to be clean with adequate seating for resident use. LPA observed the living room to contain an adequately screened fireplace and activities for resident use. LPA observed one (1) hallway closet to contain non-perishable foods and emergency water supplies. One (1) additional hallway closet was observed to contain extra care supplies. LPA observed one (1) railing support in the hallway to be detached from the railing. The office was observed to be locked and inaccessible to clients in care. At 11:23 AM LPA observed the sliding door screen to contain a tear in the screen material. The facility’s fire and carbon monoxide alarms were tested at 11:33 AM. The facility’s fire alarm functioned properly at the time of the visit. At 11:33 AM LPA observed the facility’s carbon monoxide alarm to fail to function during the test. The facility backup Administrator replaced the carbon monoxide alarm at the time of the visit. All exits in the facility were observed to contain functioning auditory alarms.

BEDROOMS: There are seven (7) bedrooms in the facility; six (6) are single occupancy resident rooms and one (1) is a staff room. LPA and facility staff toured all six (6) resident bedrooms. All resident rooms were observed to be furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting. At 11:26 AM LPA observed bedroom #1’s sliding screen door to contain a tear in the screen material.

BATHROOMS: There are three (3) bathrooms at the facility. Two (2) bathrooms are designated as shared resident bathrooms and one (1) bathroom is designated as a staff bathroom. Both resident bathrooms were observed to be clean and in good repair and were equipped with nonskid surfaces. Grab bars were observed in all resident showers and near all resident toilets, all were properly secured. The water temperature was measured between 141.4 and 163.6 degrees Fahrenheit, which is outside of the range required by regulation.

OUTDOOR SPACE: The facility has three (3) emergency exit gates. Two (2) are located in the front yard and one (1) is located in the backyard; LPA observed clear passageways for emergency exit use. The facility has adequate seating outdoors for resident use. At 11:24 PM LPA observed the facility’s backyard to be missing adequate shade for the seating area. LPA observed all rails to be appropriately secured at the time of the visit.
Continued on LIC 809C.
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Trevor Byrne
LICENSING EVALUATOR SIGNATURE:

DATE: 02/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/18/2025
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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: ELDERCARE HOMES, INC.
FACILITY NUMBER: 195850216
VISIT DATE: 02/18/2025
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GARAGE: LPA observed the garage to be locked and inaccessible to clients in care. The garage was observed to contain cleaning supplies and extra care supplies, household tools, and chemicals.

RECORD REVIEW: Record review began at 11:40 AM. Staff and resident records were reviewed for documents including, but not limited to: health screening, TB test, staff training records, fingerprint clearance, resident physician's report, needs and service appraisal, consent forms, and personal rights. Six (6) staff files were reviewed. One (1) staff file was observed to be missing the required LIC 501 Personnel Record sheet and LIC 508 Out-of-state disclosure sheet. One (1) staff file was observed to be missing the LIC 503 Health screening report – facility personnel and a negative TB test. One (1) file for a staff member, who was working at the time of the inspection, was not located at the facility. LPA observed all caregiver staff members to be missing adequate trainings conducted within the last 12 months. Four (4) resident files were reviewed. One (1) resident’s physician report was observed to not be updated following a change in condition. Additionally, the resident's file was observed to be missing a negative TB test.

MEDICATION REVIEW: Medication review began at 01:50 PM. Medications for four (4) of four (4) residents were observed. All medications were stored properly and were appropriately documented on their respective centrally stored medication and destruction record sheets. No deficiencies were observed during medication review.

INFECTION CONTROL/EMERGENCY DISASTER PLANNING: During today’s visit, the LPA reviewed the
facility's infection control practices and the facility's emergency disaster plan. The facility’s policies and procedures as it pertains to infection control are adequate. Emergency disaster drills are conducted quarterly; the facility’s last emergency disaster drill was conducted on 01/10/2025. LPA observed the facility to be utilizing an out-of-date LIC 610E, Emergency Disaster Plan for Residential Care Facilities for The Elderly. The infection control plan is reviewed/updated annually by the facility’s Administrator.

INTERVIEWS: LPA interviewed two (2) residents. The residents interviewed stated that the staff treat them well and are attentive to their needs. LPA interviewed two (2) staff members. Both staff members interviewed were knowledgeable on the resident’s rights, the forms of abuse, and the appropriate reporting procedures for suspected abuse.

Continued on LIC 809C.

SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Trevor Byrne
LICENSING EVALUATOR SIGNATURE:

DATE: 02/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/18/2025
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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: ELDERCARE HOMES, INC.
FACILITY NUMBER: 195850216
VISIT DATE: 02/18/2025
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During today’s visit LPA obtained a copy of the facility’s LIC 500, resident roster, and liability insurance.

Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D): Exit interview conducted and copy of the report was issued and appeal rights provided.

SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Trevor Byrne
LICENSING EVALUATOR SIGNATURE:

DATE: 02/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/18/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/18/2025 05:10 PM - It Cannot Be Edited


Created By: Trevor Byrne On 02/18/2025 at 04:13 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: ELDERCARE HOMES, INC.
FACILITY NUMBER: 195850216

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/18/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1569.311
Regulations
Every residential care facility for the elderly shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 of Division 12. The department shall account for the presence of these detectors during inspections.

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 as the facility's carbon monoxide alarm was observed to be non-functional at the time of the visit which poses an immediate safety risk to persons in care.
POC Due Date: 02/18/2025
Plan of Correction
1
2
3
4
Facility backup Administrator replaced the carbon monoxide alarm at the time of the visit POC cleared.
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 as the facility's hot water temparature was measured between 141.4 and 163.6 degrees F which poses an immediate health and safety risk to persons in care.
POC Due Date: 02/19/2025
Plan of Correction
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2
3
4
Licensee will submit proof of appropriate water temparature for all 3 bathroom faucets to CCLD no later than 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.
SUPERVISOR'S NAME:Kasandra Lopez
LICENSING EVALUATOR NAME:Trevor Byrne
LICENSING EVALUATOR SIGNATURE:
DATE: 02/18/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/18/2025


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Document Has Been Signed on 02/18/2025 05:10 PM - It Cannot Be Edited


Created By: Trevor Byrne On 02/18/2025 at 04:13 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: ELDERCARE HOMES, INC.
FACILITY NUMBER: 195850216

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/18/2025

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
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2
3
4
Based on observation, the licensee did not comply with the section cited above as one railing support was observed to be in disrepair which poses a potential safety risk to persons in care.
POC Due Date: 03/04/2025
Plan of Correction
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2
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Licensee will submit proof of completed repairs to the railing support to CCLD no later than POC due date.
Type B
Section Cited
CCR
87303(c)
Maintenance and Operation
(c) All window screens shall be clean and maintained in good repair.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on observation, the licensee did not comply with the section cited above as two screen door screens were observed to have tears in the material which poses potential health or safety risk to persons in care.
POC Due Date: 03/04/2025
Plan of Correction
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Licensee will submit proof of replaced or repaired screens for the two identified doors to CCLD no later than 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.
SUPERVISOR'S NAME:Kasandra Lopez
LICENSING EVALUATOR NAME:Trevor Byrne
LICENSING EVALUATOR SIGNATURE:
DATE: 02/18/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/18/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/18/2025 05:10 PM - It Cannot Be Edited


Created By: Trevor Byrne On 02/18/2025 at 04:13 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: ELDERCARE HOMES, INC.
FACILITY NUMBER: 195850216

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/18/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(g)
Personnel Records
(g) All personnel records shall be maintained at the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above as one employees file was observed to not be located at the facility which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/04/2025
Plan of Correction
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Licensee will submit a complete employee file for the identified employee to CCLD no later than POC due date.
Type B
Section Cited
CCR
87412(a)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited aboveas two employee files were missing documents including LIC 501, LIC 508, LIC 503, and TB test which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/04/2025
Plan of Correction
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Licensee will submit the completed forms for the identified employees to CCLD no later than 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.
SUPERVISOR'S NAME:Kasandra Lopez
LICENSING EVALUATOR NAME:Trevor Byrne
LICENSING EVALUATOR SIGNATURE:
DATE: 02/18/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/18/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/18/2025 05:10 PM - It Cannot Be Edited


Created By: Trevor Byrne On 02/18/2025 at 04:13 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: ELDERCARE HOMES, INC.
FACILITY NUMBER: 195850216

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/18/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above as no employees had trainings conducted within the last 12 months which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/04/2025
Plan of Correction
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Licensee will submit proof of completed annual required trainings or enrollment in required annual trainings for all employees providing care and supervision to residents to CCLD no later than POC due date.
Type B
Section Cited
CCR
87458(c)(1)(A)
Medical Assessment
(c) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the licensed medical professional's diagnosis or diagnoses and results of an examination for all of the following: (A) Communicable tuberculosis.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above as one resident was observed to not have a negative TB test on file which poses a potential health risk to persons in care.
POC Due Date: 03/04/2025
Plan of Correction
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2
3
4
Licensee will submit proof of a completed negative TB test for the identified resident no later than 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.
SUPERVISOR'S NAME:Kasandra Lopez
LICENSING EVALUATOR NAME:Trevor Byrne
LICENSING EVALUATOR SIGNATURE:
DATE: 02/18/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/18/2025


LIC809 (FAS) - (06/04)
Page: 8 of 10
Document Has Been Signed on 02/18/2025 05:10 PM - It Cannot Be Edited


Created By: Trevor Byrne On 02/18/2025 at 04:13 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: ELDERCARE HOMES, INC.
FACILITY NUMBER: 195850216

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/18/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87463(b)
Reappraisals
(b) The reappraisal shall document significant changes in the resident's physical, mental, cognitive, behavioral, or functional condition, including those required to be documented as specified in Section 87466, Observation of the Resident.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above as one resident was observed to not have an updated medical assessment following a change in condition which poses a potential health risk to persons in care.
POC Due Date: 03/04/2025
Plan of Correction
1
2
3
4
Licensee will submit an updated medical assessment for the identified resident to CCLD no later than POC due date.
Type B
Section Cited
HSC
1569.695(a)
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:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above as the facility was using the out of date LIC 610E form which is missing required information which poses safety risk to persons in care.
POC Due Date: 03/04/2025
Plan of Correction
1
2
3
4
Licensee will submit proof of a completed and updated emergency disaster plan to CCLD no later than 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.
SUPERVISOR'S NAME:Kasandra Lopez
LICENSING EVALUATOR NAME:Trevor Byrne
LICENSING EVALUATOR SIGNATURE:
DATE: 02/18/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/18/2025


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