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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 195850421
Report Date: 04/15/2025
Date Signed: 04/15/2025 04:29:39 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/09/2025 and conducted by Evaluator Trevor Byrne
COMPLAINT CONTROL NUMBER: 29-AS-20250409100933
FACILITY NAME:MY LOVELY HOUSEFACILITY NUMBER:
195850421
ADMINISTRATOR:OHANYAN, NONAFACILITY TYPE:
740
ADDRESS:13367 BLYTHE STREETTELEPHONE:
(310) 666-3399
CITY:NORTH HOLLYWOODSTATE: CAZIP CODE:
91605
CAPACITY:5CENSUS: 4DATE:
04/15/2025
UNANNOUNCEDTIME BEGAN:
09:29 AM
MET WITH:Hripsime “Ripa” TavitianTIME COMPLETED:
04:30 PM
ALLEGATION(S):
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Facility staff did not report incidents to resident's responsible person
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Trevor Byrne conducted an unannounced complaint investigation visit at the facility at 09:29 AM. LPA met with facility staff who contacted the facility Designee Hripsime “Ripa” Tavitian. The Designee arrived to the facility at 10:10 AM the reason for the visit was explained and entrance interview was conducted. LPA and the Designee contacted the Administrator Emma Avetisyan via telephone call. The Administrator was unable to come to the facility at the time of the inspection but has designated the Designee to sign this report on their behalf.

During today’s visit LPA conducted a physical plant tour, reviewed five (5) resident files, and interviewed the Designee, the Administrator, one (1) staff and four (4) residents between 10:12 AM and 03:00 PM.

Continued on LIC-9099C
Substantiated
Estimated Days of Completion: 0
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Trevor Byrne
LICENSING EVALUATOR SIGNATURE:

DATE: 04/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
Control Number 29-AS-20250409100933
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 04/15/2025
NARRATIVE
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The allegation of “Facility staff did not report incidents to resident's responsible person” alleges that the facility did not notify the responsible party of Resident #1 (R1) of falls that R1 experienced while in the care of the facility. During interviews with residents of the facility Resident #2 (R2) stated that they experienced a fall at the facility about one month ago. Additionally, R2 stated that they suffered an incident where a table that was leaned up against a wall of the facility slipped and hit their ankle. LPA interviewed Staff #1 (S1) who remembered both of the incidents involving R2. S1 also recalled R1 experiencing a fall while at the facility. S1 stated that R1 attempted to walk without staff assistance and fell forward hitting their face on the ground. S1 stated that R1 experienced a cut on their upper lip and a scratch on their neck. S1 stated that for both R1’s and R2’s falls they notified the Administrator of the incidents. LPA reviewed the facility’s E-Folder for incident reports. LPA observed the incident folder to be empty and confirmed that no incident reports were pending review in their folder. LPA informed the Designee who stated that they were unaware of any falls occurring at the facility. LPA interviewed the Administrator who confirmed that they were aware of three (3) falls that occurred at the facility. LPA asked the Administrator if incident reports were submitted for the falls and the Administrator confirmed that they were not. The Administrator confirmed that they would submit reports for all resident incidents in the future. Based on the information obtained during interviews and file review there is sufficient evidence to support the allegation of “Facility staff did not report incidents to resident's responsible person.” Therefore, the allegation is deemed Substantiated at this time.

The following deficiency was cited (refer to LIC 9099D). This report was read to the Administrator via telephone call. A copy of the report was printed, appeal rights were provided, and exit interview was conducted.
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Trevor Byrne
LICENSING EVALUATOR SIGNATURE:

DATE: 04/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/09/2025 and conducted by Evaluator Trevor Byrne
COMPLAINT CONTROL NUMBER: 29-AS-20250409100933

FACILITY NAME:MY LOVELY HOUSEFACILITY NUMBER:
195850421
ADMINISTRATOR:OHANYAN, NONAFACILITY TYPE:
740
ADDRESS:13367 BLYTHE STREETTELEPHONE:
(310) 666-3399
CITY:NORTH HOLLYWOODSTATE: CAZIP CODE:
91605
CAPACITY:5CENSUS: 4DATE:
04/15/2025
UNANNOUNCEDTIME BEGAN:
09:29 AM
MET WITH:Hripsime “Ripa” TavitianTIME COMPLETED:
04:30 PM
ALLEGATION(S):
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Facility staff did not assist resident with medical appointments
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Trevor Byrne conducted an unannounced complaint investigation visit at the facility at 09:29 AM. LPA met with facility staff who contacted the facility Designee Hripsime “Ripa” Tavitian. The Designee arrived to the facility at 10:10 AM the reason for the visit was explained and entrance interview was conducted. LPA and the Designee contacted the Administrator Nona Ohanyan via telephone call. The Administrator was unable to come to the facility at the time of the inspection but has designated the designee to sign this report on their behalf.

During today’s visit LPA conducted a physical plant tour, reviewed five (5) resident files, and interviewed the Designee, the Administrator, one (1) staff and four (4) residents between 10:12 AM and 03:00 PM.

Continued on LIC-9099
Unsubstantiated
Estimated Days of Completion: 0
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Trevor Byrne
LICENSING EVALUATOR SIGNATURE:

DATE: 04/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 29-AS-20250409100933
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 04/15/2025
NARRATIVE
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The allegation of “Facility staff did not assist resident with medical appointments” alleges that the facility did not assist R1 with doctor’s appointments and testing. Interviews with current residents of the facility did not reveal any concerns with residents receiving medical care or assistance in arranging appointments. Interviews with S1 revealed that they were never made aware of R1 requiring assistance in arranging or transport to medical appointments or testing. During the interview with the Designee they stated that R1 was a resident of the facility for such a short time and denied the responsible party of R1 ever making the facility aware of needed testing’s or appointments. The Designee stated that appointments for residents are conducted with physicians either in person or over Facetime. Additionally, the Designee revealed that the facility has contact with a mobile doctor that can evaluate residents if needed. LPA interviewed the Administrator who denied R1's representatives ever informing them of a doctor's appointment or test for R1. The Administrator confirmed that R1 resided at the facility from 03/24/2025-04/09/2025. Although the allegation may have happened or is valid there is insufficient evidence to support the allegation of, “Facility staff did not assist resident with medical appointments.” Therefore, the allegation is deemed Unsubstantiated at this time.

This report was read to the Administrator via telephone call. A copy of the report was printed, and exit interview was conducted.
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Trevor Byrne
LICENSING EVALUATOR SIGNATURE:

DATE: 04/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 29-AS-20250409100933
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/15/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/29/2025
Section Cited
CCR
87211(a)(1)
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87211 Reporting Requirements
(a) Each licensee shall...
(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days...
This requirement is not met as eviednced by:
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Licensee will subimt a statement of understanding confirming that they understand the improtance of timely reporting to CCLD no later than POC due date.
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Based on interviews and record review the licensee did not comply with the section cited above as residents experienced three falls at the facility which were not reported to the resident's responsible parties or CCLD which poses a potential health, safety, or personal rights risk to clients in care.
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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.
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Trevor Byrne
LICENSING EVALUATOR SIGNATURE:

DATE: 04/15/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5