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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195850373
Report Date: 09/27/2023
Date Signed: 09/28/2023 11:01:14 AM

Document Has Been Signed on 09/28/2023 11:01 AM - 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:MSH SENIOR LIVINGFACILITY NUMBER:
195850373
ADMINISTRATOR:BADALYAN, NAIRAFACILITY TYPE:
740
ADDRESS:11556 VALERIO STREETTELEPHONE:
(818) 565-9740
CITY:NORTH HOLLYWOODSTATE: CAZIP CODE:
91605
CAPACITY: 6CENSUS: 0DATE:
09/27/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Naira BadalyanTIME COMPLETED:
02:00 PM
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Licensing Program Analyst (LPA) Sandra Urena conducted a pre-licensing visit to the above noted facility. The LPA met with applicant, Naira Badalyan. This is an application for a new facility. A dementia program was included in the plan of operation. A Hospice Waiver has been requested and approved for six (6) residents.

At 10:15 a.m., the LPA and the applicant conducted a physical plant tour inside and out to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The facility is a one-story dwelling. An approved fire clearance was received on 07/27/2023, clearing them for four (4) non-ambulatory residents; one (1) bedridden resident, and one (1) ambulatory resident.

KITCHEN: Kitchen knives are stored in a locked box located on top of the kitchen counter. The supply of dishes, utensils, pots, pans, and drinkware is adequate. The temperatures for the refrigerator and freezer were not checked, due to thermometers missing to gauge the temperatures. The supply of nonperishable food is adequate. There are no pesticides (poisons) or toxins stored in any food storage area or preparation area with utensils. Appliances in the kitchen were clean and all appeared functional. Trash cans had tight fitting lids. Kitchen, laundry and house cleaning supplies are stored and locked in the garage area. No flies or other vermin were observed.

BEDROOMS: The facility has two (2) private residents’ bedrooms: rooms 1 and room 4; and two (2) shared room(s), room 2 and room 3. One residents’ bedroom, Room # 2 has a direct exit to the patio. The bedroom’s sliding door needs to be flushed with the floor for easy transfer from bedroom to outdoor area. Shared bedroom # 2 has been approved and cleared for one bedridden resident. Bedrooms 1, 2, 3, & 4, need a chair. All bedrooms were set up with night stands, lamps, and closet space.
Continues on LIC 809C...
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Sandra Urena
LICENSING EVALUATOR SIGNATURE: DATE: 09/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/27/2023
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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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: MSH SENIOR LIVING
FACILITY NUMBER: 195850373
VISIT DATE: 09/27/2023
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All beds were furnished with box springs, comfortable mattress and clean linen, which includes, a mattress pad, top and bottom linens, pillowcases, blanket (if needed) and a bedspread. Lighting in the rooms appeared adequate. The bedrooms were large enough to allow for easy passage between the beds and furniture with a wheelchair or walker. In addition, no bedroom was used as a passageway to another room, bath, or toilet. There are no staff rooms – ‘awake night staff only’ - is required. All rooms were free of odors. All window screens were clean and maintained in good repair.

BATHROOMS: There are two (2) bathrooms in the hallway, one is shower only and one has a bathtub. Bathrooms have non-skid mats. The toilet and shower have grab bars. Hot water temperature was tested in the bathroom(s) #1 and 2 and was recorded at 114.1 degrees Fahrenheit. Kitchen water was recorded at 112.3 degrees Fahrenheit.

COMMON AREAS: The common areas were appropriately furnished, and the lighting was adequate. There are televisions and other entertainment equipment, games and/or activity supplies in the living room and dining area There was sufficient space to accommodate both indoor and outdoor activities. Night lights were observed in hallways and passageways to non-private bathrooms. The dining room sliding door needs to be flushed with outdoor ramp at the level where wheelchairs and walkers may enter and exit the facility safely.

Outdoor ramps in patio room from dining room to patio room, and patio room to outdoor require to be leveled and flushed for easy passage with a non-slippery ramp and positioned at the level where wheelchairs and walkers may enter and exit the facility safely. There is a fireplace in the living room, which is covered with a fire safe cover. Alarms on all exterior doors were engaged at the time of visit and functional. In addition, the physical plant is consistent with the submitted facility sketch/floor plan. The facility had emergency lighting, which included flashlights, or other battery powered lighting, and batteries. The facility has central heating system, which is able to heat rooms that residents occupy to a minimum of 68 degrees Fahrenheit; and, they have central air conditioning and are able to cool rooms to a comfortable range, not to exceed 85 degrees Fahrenheit.
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Sandra Urena
LICENSING EVALUATOR SIGNATURE:

DATE: 09/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2023
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: MSH SENIOR LIVING
FACILITY NUMBER: 195850373
VISIT DATE: 09/27/2023
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The laundry area is located in the garage. The supply of extra bed and bath linens is adequate and is located in the linen closets found in the hallway between room #2 and room #3. Personal hygiene items (shampoos, soaps) were adequate.

The facility smoke alarm system is hard wired. The smoke detectors were tested and functioned properly during the time of visit. There is one (1) fire extinguisher mounted on the wall between the kitchen and the dining room. The extinguisher did not have a purchase date receipt, consequently the LPA was unable to verify functionality.
There is a functioning telephone on the premises. The emergency exiting plans/sketch are posted on the wall by the main entrance, as well as other required postings are posted in the main entrance area.

OUTDOOR AREA: The exterior passageways were clean and clear of any obstructions. There is a covered patio area at the back of the house but is missing a table and chairs where residents can sit. The entire property is fenced. The back and sides of the house are separated from the front yard by gates at the north and south side passageways. There are no other structures on the property. There is a pool which is fenced and locked with a key. The garage is accessible from the house; the door will be maintained locked. Washer and dryer are located in the garage area, both appeared to be functional.

Resident and staff records are stored in a filing cabinet, which is currently located in the patio/office room area. Medications are centrally stored in a locked in the filing cabinet, and daily medications will be stored in a locked box in a top kitchen cabinet. The first aid supplies were complete.

At 1:30 p.m., the applicant completed Component III Orientation.

This report will be sent to the Centralized Application Bureau (CAB) once all corrections are received. You will be notified by the CAB Analyst when your license has been approved. You are not allowed to begin operating until you have been notified that your license has been approved by the CAB Analyst. Failure to comply could affect approval of your license.

Exit interview was conducted and reviewed with applicant Naira Badalyan. A copy of the report was issued.




SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Sandra Urena
LICENSING EVALUATOR SIGNATURE:

DATE: 09/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2023
LIC809 (FAS) - (06/04)
Page: 3 of 4
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: MSH SENIOR LIVING
FACILITY NUMBER: 195850373
VISIT DATE: 09/27/2023
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The following items must be corrected prior to licensure. Submit proof of correction to the LPA by 10/05/2023 to reschedule a follow-up visit, so that your application may be completed.

1. Bedrooms #1, 2, 3, and 4 need chairs.
2. Fire Extinguisher needs proof of service/purchased date.
3. Outdoor furniture for outdoor area.
4. Room # 2: The bedroom’s sliding door needs to be flushed with the floor for easy transfer from bedroom to outdoor area.
5. The dining room sliding door needs to be leveled at the level where wheelchairs and walkers may enter and exit safely. Additionally, and patio room to outdoor area needs to be flushed.
6. Refrigerator/freezer thermometers to ensure that food is kept an approved temperature for the freezer of 0 degrees Fahrenheit, and refrigerator 40 degrees Fahrenheit.


At 1:30 p.m., the applicant completed Component III Orientation.

This report will be sent to the Centralized Application Bureau (CAB) once all corrections are received. You will be notified by the CAB Analyst when your license has been approved. You are not allowed to begin operating until you have been notified that your license has been approved by the CAB Analyst. Failure to comply could affect approval of your license.


Exit interview was conducted and reviewed with applicant Naira Badalyan. A copy of the report was issued.


SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Sandra Urena
LICENSING EVALUATOR SIGNATURE:

DATE: 09/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2023
LIC809 (FAS) - (06/04)
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