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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195850361
Report Date: 09/10/2025
Date Signed: 09/10/2025 03:28:24 PM

Document Has Been Signed on 09/10/2025 03:28 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:MARY'S CHATEAU IIIFACILITY NUMBER:
195850361
ADMINISTRATOR/
DIRECTOR:		PETIKYAN, MARYFACILITY TYPE:
740
ADDRESS:14835 WEDDINGTON STTELEPHONE:
(323) 333-8105
CITY:SHERMAN OAKSSTATE: CAZIP CODE:
91411
CAPACITY: 6CENSUS: 6DATE:
09/10/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:14 AM
MET WITH:Mary PetikyanTIME VISIT/
INSPECTION COMPLETED:
03:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Trevor Byrne arrived at the facility unannounced to conduct the required annual visit at 10:14 AM. LPA met with facility staff who contacted the facility Administrator Mary Petikyan via telephone call. The facility Administrator arrived to the facility at 10:26 AM. Entrance interview conducted and the reason for the visit was explained.

Beginning at 10:26 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: LPA observed the kitchen area to be clean. Kitchen appliances appeared to be in operable condition. LPA observed a secured drawer to contain knives as well as a secured cabinet located under the sink which contained cleaning supplies. The facility has a sufficient supply of two (2) days perishable and seven (7) days non-perishable food. LPA observed the facility’s non-perishable food supply to contain four (4) cans of food that were approximately one (1) month past their expiration date and one (1) additional can that was dented. LPA informed the Administrator, who immediately removed the cans from the storage. Additionally, during the visit the Administrator conducted an audit of the facility’s food supplies to ensure no items near their expiration date were retained.

BEDROOMS: There are seven (7) bedrooms in the facility; six (6) are designated as single occupancy resident rooms and one (1) is designated as a staff room. LPA and facility Administrator toured all seven (7) bedrooms. 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 were functional at the time of the visit. LPA observed the staff bedroom to be properly secured. Additionally, the staff room contained an extra refrigerator, an adequate supply of emergency water, and extra care supplies. Report Continued on LIC 809-C

NAME OF LICENSING PROGRAM MANAGER: Kasandra Lopez
NAME OF LICENSING PROGRAM ANALYST: Trevor Byrne
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/10/2025
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.

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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: MARY'S CHATEAU III
FACILITY NUMBER: 195850361
VISIT DATE: 09/10/2025
NARRATIVE
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BATHROOMS: There are four (4) bathrooms at the facility. Three (3) bathrooms are designated as shared resident bathrooms and one (1) is designated as a private resident bathroom. All bathrooms were observed to be clean and in good repair and all were equipped with nonskid surfaces. Grab bars were observed in all showers and near all toilets, all were properly secured. The water temperature was measured between 106.2 and 109 degrees Fahrenheit, which is in compliance with regulation. Two (2) hallway bathrooms were observed to contain appropriately secured storage cabinets that contained resident grooming supplies.

COMMON AREAS: This includes the living room, dining room, and hallway. LPA observed the living room to be clean and properly furnished at the time of the visit. The living room contains a television, activities for resident use, and an appropriately screened fireplace. The dining room was observed to be clean and contains adequate seating for resident use. LPA observed the hallway to contain a secured laundry room that contained a washer and dryer as well as detergents and cleaning supplies. Additionally, LPA observed a hallway closet to contain clean linens for resident use. All furniture throughout the facility was observed to be clean and in good repair. The LPA observed two (2) fire extinguishers throughout the facility to be fully charged and purchased on 04/24/2025. Smoke detectors and carbon monoxide detectors were tested at 10:57 AM and were functional at the time of the visit.

OUTDOOR SPACE: The facility has two (2) emergency exit gates 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 two (2) appropriately secured sheds to contain gardening supplies and decorations. LPA observed cameras located on the exterior of the facility.

RECORD REVIEW: Record review began at 11:00 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. Six (6) resident files were reviewed. All resident files reviewed contained all required documentation. No deficiencies were observed during record review.

MEDICATION REVIEW: Medication review began at 12:25 PM. Medications are stored centrally and securely in a cabinet in the living room. Medications for two (2) residents were observed. All medications observed were documented appropriately on their respective centrally stored medication and destruction record sheets. No deficiencies were observed during medication review. Report Continued on LIC 809-C

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

DATE: 09/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2025
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: MARY'S CHATEAU III
FACILITY NUMBER: 195850361
VISIT DATE: 09/10/2025
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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 they pertain to infection control are adequate. Emergency disaster drills are conducted quarterly and the last emergency disaster drill was conducted on 07/14/2025. 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 one (1) staff and one (1) resident. The resident interviewed stated that staff treat them very well and are attentive to their needs. The resident interviewed had no concerns with the facility. The staff member interviewed was knowledgeable on their roles and responsibilities, the resident rights, the different 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 deficiency was cited (refer to LIC 809-D): Exit interview conducted and copy of the report was issued and appeal rights provided.

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

DATE: 09/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/10/2025 03:28 PM - It Cannot Be Edited


Created By: Trevor Byrne On 09/10/2025 at 02:41 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: MARY'S CHATEAU III
FACILITY NUMBER: 195850361

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/10/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87555(b)(8)
General Food Service Requirements
(b) The following food service requirements shall apply: (8) All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above as four cans of food that expired approximatley one month ago and one damaged can of food were observed in the facility's pantry which posed a potential health risk to persons in care.
POC Due Date: 09/10/2025
Plan of Correction
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Audit of facility food stores was conducted during visit and all expired food was removed by the facility's Administrator. POC cleared.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Kasandra Lopez
NAME OF LICENSING PROGRAM MANAGER:
Trevor Byrne
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/10/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/10/2025


LIC809 (FAS) - (06/04)
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