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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195850401
Report Date: 02/25/2025
Date Signed: 02/26/2025 08:58:04 AM

Document Has Been Signed on 02/26/2025 08:58 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:PRESTIGE RESIDENTIAL CARE FACILITYFACILITY NUMBER:
195850401
ADMINISTRATOR/
DIRECTOR:		SADOYAN, NELLIFACILITY TYPE:
740
ADDRESS:6019 WILLOWCREST AVETELEPHONE:
(818) 429-9809
CITY:NORTH HOLLYWOODSTATE: CAZIP CODE:
91606
CAPACITY: 5CENSUS: 4DATE:
02/25/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:15 AM
MET WITH:Nelly SadoyanTIME VISIT/
INSPECTION COMPLETED:
04:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Valeria Conway arrived at the facility unannounced to conduct a required annual visit at 10:15 A.M. LPA met with facility Administrator Nelly Sadoyan and discussed the reason for today's visit. At 10:45 A.M. House Manager, Hrant Narinyan joined the visit. Entrance interview conducted.

At 10:30 A.M., LPA, along with Administrator, toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The following was observed:

Fire Extinguisher was observed to be fully charged and purchased during today’s visit. Hardwired combination smoke detectors and carbon monoxide detectors were tested at 12:52 P.M. and were functional at the time of the visit.

COMMON SPACES: In the common areas, including dining room and living room, walls and flooring were checked for cleanliness and good condition. At the time of the visit, furniture was observed to be in good condition. The LPA observed the required postings in the common area. LPA observed the fireplace in the living room, which was adequately screened. Auditorial signal was observed to be in working conditions at the time of the visit. Facility has three fire doors to contain a fire from one side of the house to the other side. At the time and during the visit, LPA observed two (2) doors kept open by a chair in room number #2 and by a walker in room #3. These items prevent fire door from closing and violates fire codes. During today’s visit administrator removed items and fire doors were closed. LPA observed a ring doorbell, administrator did not know that a waiver is required to have ring doorbell. LPA did not cite but advised the licensee to submit a waiver for the Ring doorbell due to the audio component, to update plan of operation and admission agreement.

Continued on LIC 9099-C

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Valeria Conway
LICENSING EVALUATOR SIGNATURE: DATE: 02/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/25/2025
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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Document Has Been Signed on 02/26/2025 08:58 AM - It Cannot Be Edited


Created By: Valeria Conway On 02/25/2025 at 03:36 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: PRESTIGE RESIDENTIAL CARE FACILITY
FACILITY NUMBER: 195850401

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/25/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87202(a)
Fire Clearance
(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal:

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 by having items obstructing fire doors which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/25/2025
Plan of Correction
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Administrator removed items and fire doors were closed during today's visit.
Type A
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

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 by having hot water over the requiered range which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/26/2025
Plan of Correction
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Administrator lower the temperature gage on the main water tank to maintain a range of 105-120 degree F.
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:Desaree Perera
LICENSING EVALUATOR NAME:Valeria Conway
LICENSING EVALUATOR SIGNATURE:
DATE: 02/25/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/25/2025


LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 02/26/2025 08:58 AM - It Cannot Be Edited


Created By: Valeria Conway On 02/25/2025 at 03:36 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: PRESTIGE RESIDENTIAL CARE FACILITY
FACILITY NUMBER: 195850401

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/25/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(5)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers.

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 by having 4 day medication supply inside medication organizer which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/26/2025
Plan of Correction
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Moving forward administrator will not utilize medication organizer for any residents in care.
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.
SUPERVISOR'S NAME:Desaree Perera
LICENSING EVALUATOR NAME:Valeria Conway
LICENSING EVALUATOR SIGNATURE:
DATE: 02/25/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/25/2025


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: PRESTIGE RESIDENTIAL CARE FACILITY
FACILITY NUMBER: 195850401
VISIT DATE: 02/25/2025
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Continued from LIC-9099

BEDROOMS: The LPA observed the resident bedrooms, which were furnished appropriately with clean linens, and sufficient lighting. There are three (3) total bedrooms. Two (2) shared rooms and one (1) private room.

BATHROOMS: The LPA observed 2 shared bathrooms and one shower room equipped with just a shower stall. Grab bars, slip-resistant mat and a shower chairs were observed. Resident restrooms are clean and sanitary. Between 10:31 A.M. and 10:47 A.M. hot water temperature was measured in all residents’ bathrooms, however, measurements were above the required range of 105 degrees Fahrenheit to 120 degrees Fahrenheit at the time of the visit. During today’s visit administrator lower the temperature gage on the main water tank to maintain a range of 105-120 degree F. LPA observed cleaning supplies and disinfectants inside a locked cabinet under the sink in hallway bathroom.



KITCHEN: Kitchen appliances appeared to be in operable condition. The facility has a sufficient supply of perishable and non-perishable food, as well as emergency supply. LPA conducted a review of expiration dates on product labels. LPA observed locked medication inside the refrigerator. All knives and sharps were observed to be locked and properly stored at the time of the visit. At 10:50 A.M. hot water temperature measured at 139.5 degrees Fahrenheit. Cleaning compounds were and separately from food supplies.

OUTDOOR SPACE: The front yard area includes a gazebo furnished with a table and chairs for resident use. At the time of the visit LPA observed that the cover, which is design to provide shade for individuals seated beneath the gazebo, was missing. The administrator stated that the cover had been torn off by the wind and that a replacement will be purchased. Technical Violation (TV) issued. There is one (1) side gate doors with self-latching mechanisms. Passageways were observed to be clear and free of hazards. There were no bodies of water noted.

LAUNDRY ROOM: The washer and dryer were observed inside a closet located between the kitchen and the office. At the time of the visit, the closet door was unlocked. LPA did not observe any cleaning supplies or detergents inside the closet at the time of the visit.

Continued from LIC 9099-C
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Valeria Conway
LICENSING EVALUATOR SIGNATURE:

DATE: 02/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/25/2025
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: PRESTIGE RESIDENTIAL CARE FACILITY
FACILITY NUMBER: 195850401
VISIT DATE: 02/25/2025
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Continued from LIC-9099C

OFFICE: Located in the central area of the residence is an office. During today’s visit, the LPA observed that this office has doors leading to both wings of the house, and these doors were unlocked and wide open. The office is used by the administrator to store resident and employee files. Additionally, the LPA observed an unlocked chest of drawers located adjacent to the file cabinet; within two (2) of the drawers, medication such as TUMS, Pepto-Bismol, Cream USP 2.5%, Gas relief and Tylenol were noted. According to the administrator, these medications belong to the staff/caregivers. After reviewing resident’s records LPA observed that no current resident is at risk if allowed access to personal grooming and hygiene items. Technical Violation (TV) issued. Furthermore, the LPA observed a closet containing clothing items, emergency water, extra paper towels and an emergency grab-and-go bag with flashlights and resident’s spare files.

DETACHED GARAGE: During today’s visit LPA inspected the detached locked garage. LPA observed wheelchairs and boxes. The garage stores items that belong to the property owner. Although the facility sketch includes the garage, the lease agreement between administrator and homeowner explicitly states that the garage space is not included in the lease and the homeowner retains access to this space at any time during the term of the lease.

RECORD REVIEW: Began at 12:45 P.M., 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, and personal rights. Two (2) resident records reviewed were missing consent form (LIC 627C). LPA emailed form to administrator and requested to include it in current and future residents. Technical Assistance was issued. Administrator will provide proof of complete form both resident. All other required forms were complete and up to date. Three (3) staff files reviewed, all containing necessary documents.

Continued on LIC 9099-C
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Valeria Conway
LICENSING EVALUATOR SIGNATURE:

DATE: 02/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/25/2025
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: PRESTIGE RESIDENTIAL CARE FACILITY
FACILITY NUMBER: 195850401
VISIT DATE: 02/25/2025
NARRATIVE
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Continued from LIC 9099-C

MEDICATION REVIEW: Began at 2:00 P.M.; LPA reviewed medication log for all four (4) residents. Facility maintains medication in a locked kitchen cabinet. Medications are labeled and checked for expiration dates. During medication audit, LPA observed that administrator has medication for all 4 residents separated in a weekly pill organizer. LPA explained that medication shall be stored in its originally received container.

LPA also reviewed the facility's Emergency Disaster Plan and Infectious Control Plan, which were observed to be complete and updated on 1/5/2025. Emergency Disaster drills are conducted quarterly, with the last drill documented on 1/5/2025. During today’s visit LPA obtained a copy of the facility’s LIC 500, resident roster, and liability insurance.


A $500 immediate civil penalty is assessed today. The administrator was informed that additional civil penalties might be assessed based on Health and Safety Code 1569.49(e) and 1569.49(f).

Pursuant to Title 22 of the CA Code of Regulations and/or CA Health and Safety Code, the following deficiencies were cited (refer to LIC 809-D):


Exit interview conducted, appeal rights discussed, and a copy of this report issued.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Valeria Conway
LICENSING EVALUATOR SIGNATURE:

DATE: 02/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/25/2025
LIC809 (FAS) - (06/04)
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