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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195850317
Report Date: 02/04/2025
Date Signed: 02/04/2025 02:43:16 PM

Document Has Been Signed on 02/04/2025 02:43 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:STARLIGHT FACILITY INC.FACILITY NUMBER:
195850317
ADMINISTRATOR/
DIRECTOR:		TADEVOSYAN, NELLIFACILITY TYPE:
740
ADDRESS:7647 TUJUNGA AVE.TELEPHONE:
(818) 378-7069
CITY:NORTH HOLLYWOODSTATE: CAZIP CODE:
91605
CAPACITY: 6CENSUS: 5DATE:
02/04/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Nelli TadevosyanTIME VISIT/
INSPECTION COMPLETED:
03:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Trevor Byrne arrived at the facility unannounced to conduct a required annual visit at 09:00 AM. LPA met with facility staff who contacted the facility administrator Nelli Tadevosyan. The Administrator arrived to the facility at 09:17 AM. Entrance interview conducted and the reason for the visit was explained.

Beginning at 09:17 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 cabinet to contain resident medications and a first aid kit. LPA observed a properly secured under-sink cabinet to contain cleaning supplies. One (1) cabinet was observed to contain adequate emergency food and water supplies. The oven was observed to be equipped with child proofing knobs rendering the appliance inoperable while not in use.

Continued on LIC 809C.
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Trevor Byrne
LICENSING EVALUATOR SIGNATURE: DATE: 02/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/04/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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Document Has Been Signed on 02/04/2025 02:43 PM - It Cannot Be Edited


Created By: Trevor Byrne On 02/04/2025 at 01:22 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: STARLIGHT FACILITY INC.
FACILITY NUMBER: 195850317

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/04/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87218(a)(1)
Theft and Loss
(a) The licensee shall ensure an adequate theft and loss program as specified in Health and Safety Code Section 1569.153. (1) The initial personal property inventory shall be completed by the licensee and the resident or the resident's representative.

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 above as one resident was identified as not having an initial personal property inventory completed at the time of admission which poses a potentia personal rights risk to persons in care.
POC Due Date: 02/18/2025
Plan of Correction
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Licensee will submit a completed personal property inventory to CCL no later than POC due date.
Type B
Section Cited
CCR
87457(c)
Pre-Admission Appraisal
(c) Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of their individual service needs in comparison with the admission criteria specified in Section 87455, Acceptance and Retention Limitations.

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 above as the pre-admission appraisal for one identified resident was not completed prior to admission to the facility which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/18/2025
Plan of Correction
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Licensee will submit a completed pre-admission appraisal and appraisal needs and services plan for the identified resident to CCL 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: 02/04/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/04/2025


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Document Has Been Signed on 02/04/2025 02:43 PM - It Cannot Be Edited


Created By: Trevor Byrne On 02/04/2025 at 01:22 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: STARLIGHT FACILITY INC.
FACILITY NUMBER: 195850317

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/04/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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
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Based on record review, the licensee did not comply with the section cited above as one identified resident's file did not contain proof of a negative TB test which poses a potential health risk to persons in care.
POC Due Date: 02/18/2025
Plan of Correction
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Licensee will submit proof of a negative TB test for the identified resident to CCL no later than POC due date.
Type B
Section Cited
CCR
87507(c)
Admission Agreements
(c) Admission agreements shall be signed and dated, acknowledging the contents of the document, by the resident or the resident's representative, if any, and the licensee or the licensee's designated representative no later than seven days following admission. Attachments to the agreement may be utilized as long as they are also signed and dated as prescribed above.

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 one resident's admission agreement was not signed within 7 days of residing at the facility which posed a potential personal rights risk to persons in care.
POC Due Date: 02/04/2025
Plan of Correction
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Administrator and resident signed the admission agreement 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: 02/04/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/04/2025


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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: STARLIGHT FACILITY INC.
FACILITY NUMBER: 195850317
VISIT DATE: 02/04/2025
NARRATIVE
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COMMON AREAS: This includes the living room, hallway, and dining area. 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 dining area contained a cabinet and drawers with activities for resident use. LPA observed a fire extinguisher mounted in the dining area to be fully charged and purchased on 01/18/2025. The living room was observed to be clean and in good repair. The living room contained adequate seating for resident use. LPA observed the living room to contain an adequately screened fireplace. LPA observed a hallway closet to contain extra linens. The facility’s combination fire and carbon monoxide alarms were tested at 10:01 AM and were functional at the time of the visit.

BEDROOMS: There are four (4) bedrooms in the facility; three (3) are a dual occupancy resident rooms and one (1) is a staff room. LPA and facility administrator toured all four (4) bedrooms. All resident rooms were observed to be furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting. One (1) resident bed was observed to contain full bed rails. Auditory alarms were observed on facility exits and all were functional at the time of the visit.

BATHROOMS: There are two (2) bathrooms at the facility. One (1) bathroom is designated as private resident bathroom, and one (1) bathroom is designated as a shared resident 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 118.9 and 120 degrees Fahrenheit, which is in compliance with regulation. LPA observed both bathrooms to contain appropriately secured under-sink cabinets containing cleaning supplies and personal grooming supplies for resident use.

OUTDOOR SPACE: The facility has two (2) emergency exit gates. One (1) is 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 shaded seating outdoors for resident use. LPA observed the facility’s backyard to contain an appropriately fenced off pool that was inaccessible to residents in care.

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

DATE: 02/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/04/2025
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: STARLIGHT FACILITY INC.
FACILITY NUMBER: 195850317
VISIT DATE: 02/04/2025
NARRATIVE
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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, extra care supplies, an extra refrigerator, and an extra freezer. The extra refrigerator was observed to contain resident medications that required refrigeration.

RECORD REVIEW: Record review began at 10:02 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. Four (4) staff files were reviewed. All staff files contained the required documents and trainings. Five (5) resident files were reviewed. One (1) resident’s admission agreement was observed to be missing signatures. One (1) resident file was observed to be missing a property and valuables sheet, a preadmission appraisal, and a negative Tuberculosis (TB) test.

MEDICATION REVIEW: Medication review began at 11:45 AM. Medications for two (2) 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 01/04/2025. 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 two (2) residents. The residents interviewed stated that the staff treat them well and are attentive to their needs. Both residents had no concerns with the facility. No staff interviews were able to be conducted at the time of the visit as one (1) staff member had to leave the facility and the Administrator was the only available representative at the time of the visit.

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: 02/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/04/2025
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