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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195850421
Report Date: 07/01/2024
Date Signed: 07/02/2024 07:45:46 AM

Document Has Been Signed on 07/02/2024 07:45 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: 5CENSUS: 0DATE:
07/01/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Nona OhanyanTIME VISIT/
INSPECTION COMPLETED:
11:45 AM
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Licensing Program Analyst (LPA) Sandra Urena conducted a follow up Pre-licensing visit to the facility. LPA met with applicant Nona Ohanyan. Entrance interview conducted. This is a Change of Ownership(CHOW) application for five (5) residents. A Hospice Waiver for five (5) residents has been granted. 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.

On 05/23/2024, LPA Urena conducted an initial visit, and corrections were needed during the visit.
Administrator agreed to do the following corrections.

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


This report will be sent to the Centralized Application Unit (CAB) 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 CAB Analyst. Failure to comply could affect approval of your license.

Exit interview was conducted and a copy of the report was issued.

SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Sandra Urena
LICENSING EVALUATOR SIGNATURE: DATE: 07/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/01/2024
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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