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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195850280
Report Date: 11/15/2024
Date Signed: 11/15/2024 02:44:35 PM

Document Has Been Signed on 11/15/2024 02:44 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:FRIENDSHIP VILLAGE RCFFACILITY NUMBER:
195850280
ADMINISTRATOR/
DIRECTOR:		MKRTCHIAN, VAHEFACILITY TYPE:
740
ADDRESS:12950 HAYNES STTELEPHONE:
(818) 414-0005
CITY:NORTH HOLLYWOODSTATE: CAZIP CODE:
91606
CAPACITY: 6CENSUS: 5DATE:
11/15/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Vahe Mkrtchian - AdministratorTIME VISIT/
INSPECTION COMPLETED:
03:00 PM
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(PAGE 1)

Licensing Program Analyst (LPA) Erica Mosley arrived at the facility unannounced to conduct a required annual visit at 10:00 a.m. Upon arrival, there was two (2) staff and five (5) residents present. Staff called Administrator and arrived shortly after. The LPA met with Administrator Vahe Mkrtchian and explained the reason for the visit. The LPA 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.

KITCHEN: The LPA toured the kitchen/food service area at 10:26 a.m. The hot water was measured at 114.4 degrees Fahrenheit at 10:30 a.m. within the required range. The kitchen appeared clean and the appliances and fixtures functional. Refrigerated and frozen foods were stored at proper temperature. There was a sufficient supply of two (2) day perishable and seven (7) day non-perishable food. The facility also received a food delivery during the visit. Administrator stated they have groceries regularly delivered on Fridays. Food labels were inspected and checked for dates and expiration dates. Food had labels clearly marked with dates. Knives and sharps were observed locked in a cabinet. Cleaning supplies were stored under the kitchen sink locked and inaccessible. There were no pesticides or poisons observed near any food areas. An adequate supply of emergency food is located in the bottom cabinet in the kitchen.

(Report Continued on LIC 809C 2ND PAGE)
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Erica Mosley
LICENSING EVALUATOR SIGNATURE: DATE: 11/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/15/2024
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 3
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: FRIENDSHIP VILLAGE RCF
FACILITY NUMBER: 195850280
VISIT DATE: 11/15/2024
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(PAGE 2) (Report Continued from LIC 809 PAGE 1)

LIVING ROOM/DINING ROOM/ COMMON SPACE: The LPA inspected the living room and dining room area. The common areas were observed to be properly furnished and clean at the time of the visit. Furniture was observed to be in good condition. The facility maintained a comfortable temperature. At 11:36 a.m., the hardwired smoke detector(s) and carbon monoxide detectors were tested and operational. Fire extinguisher was observed fully charged and purchased on 12/13/2023. The LPA observed required postings throughout the common spaces. The facility has a working telephone on premises. Auditory alarms on all doors were functional at the time of the visit. Entry/exits were free of obstruction. The last emergency disaster drill took place on 08/27/2024 and are conducted quarterly. Activities were observed in the common areas. There was a linen closet in the hallway with extra towels and linens. Cleaning supplies and toxins were observed in the hallway closet which remains locked, and inaccessible to residents in care.

GARAGE /OUTDOORS: There is a garage that is kept locked and inaccessible at all times and is used as storage. The LPA observed a sufficient supply of Personal Protectant Equipment (PPE). The front yard has a shaded area with furniture for resident use. The backyard also has a shaded area with chairs and physical activity equipment such as a stationary bike for resident use. The LPA observed two (2) gates that self-latches with a clear passageway in case of an emergency. There were no bodies of water noted at the time of the visit. There is a washer and dryer on the premises.



BEDROOMS: There are five (5) total bedrooms in the facility, two (2) are designated as shared, double occupancy resident bedrooms, two (2) are designated as private, single occupancy resident bedrooms, and one (1) staff room which remains locked at all times. The resident bedrooms were properly furnished with a bed, nightstand, and sufficient lighting for each resident. The bedrooms had appropriate and adequate bedding and linens such as sheets, pillowcases, mattress pads, and blankets.

BATHROOMS: There are two (2) shared bathrooms for resident use. Resident bathrooms were clean, sanitary and in operating condition with grab bars and non-skid surfaces. The hot water was measured in both bathrooms. The first bathroom measured at 109.1 degrees Fahrenheit at 10:38 a.m. and the second measured at 111.6 degrees Fahrenheit at 10:40 a.m. both within the required range.
(Report Continued on LIC 809C... 3RD PAGE)
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Erica Mosley
LICENSING EVALUATOR SIGNATURE:

DATE: 11/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3
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: FRIENDSHIP VILLAGE RCF
FACILITY NUMBER: 195850280
VISIT DATE: 11/15/2024
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(PAGE 3) (Report Continued from LIC 809C 2ND PAGE)

RECORDS: Records review began at 10:43 a.m., five (5) resident records were reviewed for, but not limited to: appraisals, medical records, admissions agreement, consent forms. All files were in order at this time.

Four (4) Personnel records and Administrator’s file were reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All files were in order.


MEDICATIONS: Medications review for five (5) residents began at approximately 11: 45 a.m. Medications are centrally stored in a locked closet in the hallway inaccessible to residents in care. All medications including PRNs were labeled, stored, and locked inaccessible to residents. PRNs have physicians order on file. Medications are labeled and checked for expiration dates. No medication errors observed at this time. The facility uses an application called ALCOMY which documents medication and is used by all staff.

The LPA interviewed one (1) staff, two (2) residents during the inspection.

During today’s visit, the LPA obtained copies of the following: LIC 500 Personnel Report, LIC 9020 Resident Roster, and current liability insurance.

No deficiencies cited at this time. Exit interview conducted. A copy of the report was provided.
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Erica Mosley
LICENSING EVALUATOR SIGNATURE:

DATE: 11/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2024
LIC809 (FAS) - (06/04)
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