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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195850421
Report Date: 05/23/2024
Date Signed: 05/24/2024 08:23:44 AM

Document Has Been Signed on 05/24/2024 08:23 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:MY LOVELY HOUSEFACILITY NUMBER:
195850421
ADMINISTRATOR/
DIRECTOR:		OHANYAN, NONAFACILITY TYPE:
740
ADDRESS:13367 BLYTHE STREETTELEPHONE:
(310) 666-3399
CITY:NORTH HOLLYWOODSTATE: CAZIP CODE:
91605
CAPACITY: 6CENSUS: 0DATE:
05/23/2024
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:45 AM
MET WITH:Nona OhanyanTIME VISIT/
INSPECTION COMPLETED:
01:00 PM
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Licensing Program Analyst (LPA) Sandra Urena conducted an announced Pre-licensing visit to the facility. LPA met with applicant Nona Ohanyan. Entrance interview conducted. This is a Change of Ownership(CHOW) application for six (6) residents. A Hospice Waiver for six (6) residents has been granted.
At 9:45 a.m., the LPA, and the applicant 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.

Facility is a single-story residence, which consists of three (3) bedrooms and one (1) bathroom.
Fire Clearance was approved on 02/15/2024 for five (5) non ambulatory and one (1) bedridden resident to reside in bedroom #3. At the time of the visit, the LPA observed the facility sketch to be different than the one submitted to the Centralized Application Branch (CAB). Per the applicant an updated sketch approved by the fire department was emailed to CAB. However at the time LPA Urena received the pre-application packet, the original facility sketch was received with the packet. with the packet. The LPA will contact CAB about an updated facility sketch and a new approved fire clearance before completing the prelicencing visit.
Common Areas: These included the living room and dining area. The common areas were checked for cleanliness and furniture was checked for functionality during time of visit. Smoke detectors and Carbon Monoxide detector were tested and functioned properly during time of visit. Smoke detectors and Carbon monoxide detector are hard wired throughout the facility. Fire extinguisher was observed to be fully charged and purchased 12/11/2023. Facility accept dementia residents. The LPA observed signal alarms on exit doors.
Kitchen: The kitchen appeared clean and the appliances and fixtures functional during the time of visit. LPA observed a sufficient amount of non-perishable food at the facility; properly stored. Sharp objects will be stored in a top kitchen cabinet. Medication will be locked in cabinet in the living room area. A laundry area with a washer and dryer was observed in a corner of the kitchen area.

Conitnues on LIC 809C...

SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Sandra Urena
LICENSING EVALUATOR SIGNATURE: DATE: 05/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/23/2024
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: MY LOVELY HOUSE
FACILITY NUMBER: 195850421
VISIT DATE: 05/23/2024
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Bedrooms: The resident bedrooms were properly furnished with at least one chair, nightstand and sufficient lighting for each resident. The bedrooms had appropriate and adequate bedding and linens.

Bathrooms: LPA observed one bathroom to be clean, properly supplied and had functional fixtures. LPA observed the bathroom to have grab bars and non-skid mats. The hot water measured at 117.8 degrees Fahrenheit during visit.

Surrounding Grounds (Outdoors): LPA observed a shaded area outdoors for resident use. Appropriate outdoor furniture was present during the inspection. There are no bodies of water on the premises. There is a detached shed in the corner of the facility for storage purposes. The applicant stated they will keep door locked at all times.



Administrator agreed to send corrections to LPA by 05/29/2024.

· Change bed with adaptable rails from room #2 to room #3, which is the approved room for a bedridden resident.
· Reorganize closest for rooms # 1 and 2.
· Cell phone specifically for residents’ use.
· Facility sketch will be updated to reflect the approved fire department sketch.
· Gardening supplies will be cleared and locked in the shed.

The applicant completed Component III Orientation.


This report will be sent to the Centralized Application Unit (CAU) once all corrections are received. You will be notified by the CAU 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 CAU Analyst. Failure to comply could affect approval of your license.

Exit interview conducted/Copy of this report given

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

DATE: 05/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2024
LIC809 (FAS) - (06/04)
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