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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195850319
Report Date: 03/28/2025
Date Signed: 03/28/2025 12:24:13 PM

Document Has Been Signed on 03/28/2025 12:24 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:ANA'S RESIDENCE CARE 1FACILITY NUMBER:
195850319
ADMINISTRATOR/
DIRECTOR:		ATAYAN, ANNAFACILITY TYPE:
740
ADDRESS:7915 VAN NOORD AVENUETELEPHONE:
(323) 688-3377
CITY:NORTH HOLLYWOODSTATE: CAZIP CODE:
91605
CAPACITY: 6CENSUS: 5DATE:
03/28/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:28 AM
MET WITH:Anna AtayanTIME VISIT/
INSPECTION COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA) Trevor Byrne arrived at the facility unannounced to conduct a required annual visit at 09:28 AM. LPA met with facility staff who contacted the facility Administrator Anna Atayan. The Administrator arrived to the facility at 09:49 AM. Entrance interview conducted and the reason for the visit was explained.

Beginning at 09:50 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. The facility’s washer and dryer are located in the kitchen and a door to the garage was observed to be locked and inaccessible to clients in care. LPA observed a camera covering the kitchen area and entrance to the garage. LPA confirmed with the facility Administrator that audio is not recorded.

GARAGE: LPA observed the garage to be inaccessible to clients in care. The garage was observed to contain cleaning supplies, extra care supplies, emergency water supplies, and an extra refrigerator.

Continued on LIC 809C.

NAME OF LICENSING PROGRAM MANAGER: Kasandra Lopez
NAME OF LICENSING PROGRAM ANALYST: Trevor Byrne
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 03/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/28/2025
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: ANA'S RESIDENCE CARE 1
FACILITY NUMBER: 195850319
VISIT DATE: 03/28/2025
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COMMON AREAS: This includes the living room, Administrator’s office, hallway, and dining area. LPA observed all common areas of the facility to be clean and all furniture was observed to be in good repair. The living room contains a television, activities, and adequate seating for resident use. The Administrator’s office is located at the front of the facility and contains facility and resident files. LPA observed a hallway closet to contain extra linens and care supplies. The dining area is attached to the kitchen and contains adequate seating for resident use. LPA observed the dining area and hallway to contain fire extinguishers. Fire extinguishers were observed to be fully charged and purchased on 02/24/2025. The facility’s combination fire and carbon monoxide alarms, as well as the facility fire door, were tested at 10:23 AM and were functional at the time of the visit.

OUTDOOR SPACE: The facility has one (1) emergency exit gate located in the front yard; LPA observed clear passageways on either side of the facility for emergency exit use. The facility has adequate shaded seating outdoors for resident use. LPA observed the backyard to contain ramps and handrails leading from the exits of resident rooms. All ramps were observed to be in good repair and all handrails were properly secured.

BEDROOMS: There are six (6) bedrooms in the facility; all six (6) bedrooms are single occupancy rooms. LPA and facility Administrator toured all six (6) resident rooms. All resident rooms were observed to be clean and were 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. Bedrooms # 2,3,4,5, and 6 all contain direct exits to the outdoors of the facility.

BATHROOMS: There are four (4) bathrooms at the facility. Two (2) bathrooms are designated as private resident bathrooms, and two (2) bathrooms are designated as a shared resident bathrooms. All 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 106 and 109 degrees Fahrenheit, which is in compliance with regulation.

Continued on LIC 809C.

NAME OF LICENSING PROGRAM MANAGER: Kasandra Lopez
NAME OF LICENSING PROGRAM ANALYST: Trevor Byrne
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2025
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: ANA'S RESIDENCE CARE 1
FACILITY NUMBER: 195850319
VISIT DATE: 03/28/2025
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RECORD REVIEW: Record review began at 10:25 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. Three (3) staff files were reviewed. All staff files contained the required documents and trainings. Five (5) resident files were reviewed all resident files contained all required documentation and signatures. No deficiencies were observed during record review.

MEDICATION REVIEW: Medication review began at 11:25 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 03/21/2025. 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 and two (2) staff members. Both residents interviewed stated that the staff treat them well and are attentive to their needs. Both residents had no concerns or recommendations for improvement for the facility. Both staff interviews were conducted with the assistance of the facility Administrator acting as a translator. Both staff members 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.

No deficiencies were observed during today’s inspection. Exit interview conducted and copy of the report was issued.

NAME OF LICENSING PROGRAM MANAGER: Kasandra Lopez
NAME OF LICENSING PROGRAM ANALYST: Trevor Byrne
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2025
LIC809 (FAS) - (06/04)
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