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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195850421
Report Date: 04/15/2025
Date Signed: 04/15/2025 04:30:15 PM

Document Has Been Signed on 04/15/2025 04:30 PM - 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: 4DATE:
04/15/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:30 PM
MET WITH:Hripsime “Ripa” TavitianTIME VISIT/
INSPECTION COMPLETED:
04:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Trevor Byrne conducted an unannounced case management - deficiencies 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, one (1) staff and four (4) residents between 10:12 AM and 03:00 PM.

During file review LPA observed two (2) resident's admission agreements to be missing information. Both admission agreements were missing the rates residents were being charged for basic services. One (1) admission agreement was observed to be missing initials and signatures on all but the last page of the document.

LPA reviewed the facility personnel summary for all individuals associated and cleared to work for the facility. While reviewing this list LPA did not observe Staff #1 (S1) to be associated to the facility. S1 was observed to be working during the visit and was providing care and supervision to the residents. During an interview with S1 they revealed that they have worked for the facility for approximately 2 months. Continued on LIC 809C.
NAME OF LICENSING PROGRAM MANAGER: Kasandra Lopez
NAME OF LICENSING PROGRAM ANALYST: Trevor Byrne
LICENSING PROGRAM ANALYST 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.

LIC809 (FAS) - (06/04)
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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 04/15/2025 04:30 PM - It Cannot Be Edited


Created By: Trevor Byrne On 04/15/2025 at 03:08 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: 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 A
04/16/2025
Section Cited
CCR
87355(e)

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87355 Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility:
This requirement is not met as evidenced by:
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Licensee will submit proof of S1's association to the facility no later than POC due date.
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Based on record review the licensee did not comply with the section cited above as S1 is not associated to the facility on Guardian or LIS which poses an immediate health, safety, or personal rights risk to clients in care.
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Type B
04/29/2025
Section Cited
CCR87507(g)(3)(A)

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87507 Admission Agreements
(g) Admission agreements shall specify the following:
(3) Payment provisions, including...
(A) Rate for all basic services...
This requirement is not met as eviednced by:
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Licensee will submit proof of two completed admission agreements for the identified residents no later than POC due date.
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Based on record review the licensee did not comply with the section cited above as two residents had incomplete admission agreements that were missing the amount charged for basic services which poses a potential 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.
Kasandra Lopez
NAME OF LICENSING PROGRAM MANAGER:
Trevor Byrne
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST 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


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: 04/15/2025
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LPA informed the Administrator that having un-associated individuals providing care and supervision poses an immediate health, safety, or personal rights risk to clients in care. LPA informed the Administrator that a civil penalty in the amount of $100 per day S1 has been working, up to a maximum of five (5) days, will be assessed for a total of $500. LPA informed that Administrator that the civil penalty will be assessed on today’s date (04/15/2025). The Administrator expressed understanding and confirmed that S1 would be associated to the facility before the plan of correction due date.

Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies and civil penalty were cited (refer to LIC 809-D): Exit interview conducted and copy of the report was issued and appeal rights provided.

NAME OF LICENSING PROGRAM MANAGER: Kasandra Lopez
NAME OF LICENSING PROGRAM ANALYST: Trevor Byrne
LICENSING PROGRAM ANALYST 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
LIC809 (FAS) - (06/04)
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