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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195850373
Report Date: 10/10/2023
Date Signed: 10/11/2023 08:09:27 AM

Document Has Been Signed on 10/11/2023 08:09 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:
10/10/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Naira BadalyanTIME COMPLETED:
11:15 AM
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Licensing Program Analyst (LPA) Sandra Urena conducted a follow-up pre-licensing visit for corrections of the deficiencies noted on 09/27/2023. The LPA met with applicant, Naira Badalyan.

At 10:00 a.m., the LPA and the applicant conducted a physical plant tour inside and outside to ensure the deficiencies were corrected.

The LPA observed the following items corrected:


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

This report will be sent to the Centralized Application Bureau (CAB). 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: 10/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/10/2023
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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