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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 195850421
Report Date: 07/21/2025
Date Signed: 07/21/2025 04:22:22 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
07/14/2025 and conducted by Evaluator Trevor Byrne
COMPLAINT CONTROL NUMBER: 29-AS-20250714162452
FACILITY NAME:MY LOVELY HOUSEFACILITY NUMBER:
195850421
ADMINISTRATOR:AVETISYAN, EMMAFACILITY TYPE:
740
ADDRESS:13367 BLYTHE STREETTELEPHONE:
(310) 666-3399
CITY:NORTH HOLLYWOODSTATE: CAZIP CODE:
91605
CAPACITY:5CENSUS: 5DATE:
07/21/2025
UNANNOUNCEDTIME BEGAN:
09:59 AM
MET WITH:Albert OmurkulovTIME COMPLETED:
04:30 PM
ALLEGATION(S):
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Residents who are bedridden are being retained in a room without bedridden fire clearance
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Trevor Byrne conducted an unannounced complaint investigation visit at the facility at 09:59 AM. LPA met with staff #1 (S1) who contacted the facility Administrator Emma Avetisyan. The Administrator stated that they are unable to come to the facility during today’s visit but has designated S1 to sign this report on their behalf. Entrance interview was conducted and the reason for the visit was explained.

During today’s visit LPA conducted a physical plant tour, reviewed three (3) resident files, and conducted interviews with the Administrator, one (1) staff member, one (1) witness, and two (2) residents between 10:05 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: 07/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2025
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 3
Control Number 29-AS-20250714162452
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: 07/21/2025
NARRATIVE
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The allegation of “Residents who are bedridden are being retained in a room without bedridden fire clearance” alleges that the facility is retaining two (2) bedridden individuals in a non-bedridden approved room in violation of their fire clearance. LPA identified resident #1 (R1), and resident #2 (R2) as the subjects of the complaint. LPA conducted a physical plant tour and observed R1 and R2’s room. R2 was not present at the facility during the inspection. During the interview with S1 they confirmed that they do assist R1 and R2 with repositioning in bed. S1 stated that they assist R1 and R2 approximately every two (2) hours. S1 stated that R2 was able to reposition without assistance until approximately two (2) to three (3) weeks ago. LPA interviewed R1 who confirmed that they require assistance with repositioning in bed. During the interview R1 demonstrated the inability to reposition without assistance. Additionally, R1 stated that they and R2 are roommates. R1 confirmed that R2 requires and is being provided with assistance in repositioning in bed. LPA reviewed R1 and R2’s resident files. R1’s medical assessment dated 10/15/2024 identifies them as “non-ambulatory” and R2’s medical assessment dated 07/09/2025 identifies them as “non-ambulatory”. LPA interviewed Witness #1 (W1) who confirmed that their criteria for determining if a resident is “Non-Ambulatory” Vs. “Bedridden” includes determining the resident’s ability to reposition themselves in bed without assistance. W1 confirmed that R1 is no longer a client of their office. LPA interviewed the facility Administrator who confirmed that R1 is “Mostly” bedridden and receives assistance from staff with repositioning. The Administrator stated that R2 began needing assistance with repositioning around 07/10/2025 before their hospitalization on 07/12/2025. LPA reviewed the facility’s fire clearance and observed that the facility is cleared to retain one (1) bedridden resident in bedroom #3 only. LPA observed both R1 and R2 to reside in bedroom #1 which is only cleared for non-ambulatory residents. LPA informed the Administrator that retaining bedridden residents in a room which is designated as non-ambulatory is a violation of their fire clearance and an immediate civil penalty in the amount of $500 is being assessed on today’s date (07/21/2025). LPA informed the Administrator that per their approved fire clearance they may only retain one (1) bedridden resident and failure to relocate the bedridden resident to the bedridden approved room may result in the issuance of a 100$/day civil penalty. Based on the information obtained during interviews there is sufficient evidence to support the allegation of “Residents who are bedridden are being retained in a room without bedridden fire clearance.” Therefore, the allegation is deemed Substantiated at this time.

The following deficiency and civil penalty were 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: 07/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 29-AS-20250714162452
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: 07/21/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/22/2025
Section Cited
HSC
1569.149
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§1569.149 Fire clearance...
...the facility shall secure and maintain a fire clearance approval from the local fire enforcing agency, as defined in Section 13244, or the State Fire Marshal...
This requirement is not met as evidenced by:
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The Administrator agreed to notify the local fire department of the bedridden residents residing in the non-ambulatory room. The Administrator agreed to move one resident to the bedridden approved room. The Administrator understood that the facility is approved for one bedridden resident only.
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Based on observation, interview, and record review the licensee did not comply with the section cited above as R1 and R2 need assistance with repositioning in bed and did not reside in the bedridden approved room which poses an immediate safety 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: 07/21/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3