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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195850298
Report Date: 01/17/2025
Date Signed: 01/17/2025 03:16:05 PM

Document Has Been Signed on 01/17/2025 03:16 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:LAURELGROVE BOARD AND CAREFACILITY NUMBER:
195850298
ADMINISTRATOR/
DIRECTOR:		TADEVOSYAN, LUSINEFACILITY TYPE:
740
ADDRESS:8221 LAURELGROVE AVETELEPHONE:
(818) 355-2632
CITY:NORTH HOLLYWOODSTATE: CAZIP CODE:
91605
CAPACITY: 6CENSUS: 6DATE:
01/17/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:14 AM
MET WITH:Dianna KarapetyanTIME VISIT/
INSPECTION COMPLETED:
03:30 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) Trevor Byrne arrived at the facility unannounced to conduct a required annual visit at 09:14 AM. LPA met with facility staff who contacted the facility administrator Dianna Karapetyan. The administrator arrived to the facility at approximately 09:35 AM. Entrance interview conducted and the reason for the visit was explained.

Beginning at approximately 09:35 AM, the LPA, along with facility administrator 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 under sink cabinet to contain cleaning chemicals. LPA observed adequate emergency food and water supplies stored in a kitchen cabinet. LPA observed a fire extinguisher mounted in the kitchen to be fully charged and purchased on 01/25/2025. LPA observed the refrigerator to contain unsecured vitamins belonging to a facility staff member.

BEDROOMS: There are four (4) bedrooms in the facility; two (2) are dual occupancy rooms and two (2) are single occupancy rooms. LPA and facility administrator toured all four (4) resident rooms. All resident rooms were observed to be furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting. Auditory alarms were observed on facility exits and all were functional at the time of the visit.

Continued on LIC 809C.
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Trevor Byrne
LICENSING EVALUATOR SIGNATURE: DATE: 01/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/17/2025
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 5
Document Has Been Signed on 01/17/2025 03:16 PM - It Cannot Be Edited


Created By: Trevor Byrne On 01/17/2025 at 02:34 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: LAURELGROVE BOARD AND CARE
FACILITY NUMBER: 195850298

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/17/2025

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 as the facility's water temparature measured at resident bathroom facuets was measured between 122.4 and 134.8 degrees Fahrenheit which poses an immediate health risk to persons in care.
POC Due Date: 01/18/2025
Plan of Correction
1
2
3
4
Administrator lowered the temparature on the water heater at the time of the visit. Licensee will submit proof of appropriate water temparature to CCLD no later than 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.
SUPERVISOR'S NAME:Kasandra Lopez
LICENSING EVALUATOR NAME:Trevor Byrne
LICENSING EVALUATOR SIGNATURE:
DATE: 01/17/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/17/2025


LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 01/17/2025 03:16 PM - It Cannot Be Edited


Created By: Trevor Byrne On 01/17/2025 at 02:34 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: LAURELGROVE BOARD AND CARE
FACILITY NUMBER: 195850298

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/17/2025

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, the licensee did not comply with the section cited aboveas one (1) resident bathroom mirror was observed to be broken with a sharp edge exposed which poses a potential health risk to persons in care.
POC Due Date: 01/24/2025
Plan of Correction
1
2
3
4
Licensee will submit proof of repaired mirror to CCLD no later than POC due date.
Type B
Section Cited
CCR
87465(h)(2)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

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 unsecured vitamins belonging to a facility staff member were stored unsecured in the facility refrigerator which poses a potential health or safety risk to persons in care.
POC Due Date: 01/17/2025
Plan of Correction
1
2
3
4
Administrator secured the vitamins at the time of 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.
SUPERVISOR'S NAME:Kasandra Lopez
LICENSING EVALUATOR NAME:Trevor Byrne
LICENSING EVALUATOR SIGNATURE:
DATE: 01/17/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/17/2025


LIC809 (FAS) - (06/04)
Page: 3 of 5
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: LAURELGROVE BOARD AND CARE
FACILITY NUMBER: 195850298
VISIT DATE: 01/17/2025
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
BATHROOMS: There are four (4) bathrooms at the facility. Two (2) bathrooms are designated as private resident bathrooms, one (1) bathroom is designated as a shared resident bathroom and one (1) bathroom is designated as a staff bathroom. All 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 122.4 and 134.8 degrees Fahrenheit, which is outside the range required by regulation. One (1) private resident bathroom was observed to contain a broken mirror.

OUTDOOR SPACE: The facility has one (1) emergency exit gate located in the front yard; LPA observed clear passageways for emergency exit use. The facility has adequate shaded seating outdoors for resident use. LPA observed a locked storage shed to contain wheelchairs, tools, chemicals, and extra care supplies. The backyard was observed to contain an appropriately fenced pool that was empty of all water at the time of the visit. One (1) extra refrigerator was observed in the backyard of the facility. The back patio outside of bedroom #2 is the designated smoking area of the facility.

COMMON AREAS: This includes the living room, hallway, storage room, and dining room. LPA observed the dining room to be clean and properly furnished at the time of the visit. The dining room contains a dining table with adequate seating for resident use. The living room was observed to be clean and in good repair. The living room was observed to contain a television and activities for resident use. LPA observed a locked hallway closet to contain resident medications and facility files. The facility’s combination fire and carbon monoxide alarms were tested at 12:19 PM and were functional at the time of the visit.

RECORD REVIEW: Record review began at 10:30 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. All staff files contained the required documents and trainings. Six (6) resident files were reviewed all resident files contained all required documentation and signatures. No deficiencies were observed during record review.

Continued on LIC 809C.
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Trevor Byrne
LICENSING EVALUATOR SIGNATURE:

DATE: 01/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/17/2025
LIC809 (FAS) - (06/04)
Page: 4 of 5
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: LAURELGROVE BOARD AND CARE
FACILITY NUMBER: 195850298
VISIT DATE: 01/17/2025
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
MEDICATION REVIEW: Medication review began at 11:45 AM. Medications for three (3) of five (5) 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 01/09/2025. The facility’s emergency disaster plan is up to date and is adequate. Both the infection control plan and the emergency disaster plan are reviewed/updated annually by the facility’s administrator.

INTERVIEWS: LPA interviewed three (3) residents and two (2) staff members. Two (2) of the residents interviewed stated that the staff treat them well and are attentive to their needs. Two (2) residents had no concerns with the facility. Both staff interviews were conducted with the assistance of the facility administrator acting as a translator. Both staff interviewed understood their roles and responsibilities, The resident’s rights, the forms of abuse, and the appropriate reporting procedures for suspected abuse.

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-Ds): 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: 01/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/17/2025
LIC809 (FAS) - (06/04)
Page: 5 of 5