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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195850421
Report Date: 07/21/2025
Date Signed: 07/21/2025 04:25:05 PM

Document Has Been Signed on 07/21/2025 04:25 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:		AVETISYAN, EMMAFACILITY TYPE:
740
ADDRESS:13367 BLYTHE STREETTELEPHONE:
(310) 666-3399
CITY:NORTH HOLLYWOODSTATE: CAZIP CODE:
91605
CAPACITY: 5CENSUS: 5DATE:
07/21/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:59 AM
MET WITH:Albert OmurkulovTIME VISIT/
INSPECTION COMPLETED:
04:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Trevor Byrne arrived to the facility at 09:59 AM to conduct an unannounced Case Management visit at the facility today. 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.

During interviews and file review LPA observed Resident #1 (R1) and resident #2 (R2)’s files. LPA observed both R1 and R2 to be identified on their medical assessments as “non-ambulatory”. Interviews with the Administrator, S1, and R1 revealed that both R1 and R2 are unable to reposition in bed without the assistance of staff. LPA informed the Administrator that this is a change in condition of the residents and an updated medical assessment is required. LPA informed the Administrator that they were recently cited during the required annual visit on 07/09/2025 for a violation of CCR 87463(f). LPA informed the Administrator that this is a repeat violation of the same regulation within a twelve (12) month period. LPA informed the Administrator that a civil penalty in the amount of $250 is being assessed on today’s date (07/21/2025) for a repeat violation. `

Continued on LIC 809C.

NAME OF LICENSING PROGRAM MANAGER: Kasandra Lopez
NAME OF LICENSING PROGRAM ANALYST: Trevor Byrne
LICENSING PROGRAM ANALYST 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.

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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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: 07/21/2025
NARRATIVE
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During interviews with S1 and the Administrator LPA was informed of the recent hospitalization of R2 on 07/12/2025. LPA reviewed the facility’s file for submitted incident reports and did not observe a report submitted for R2. LPA informed the Administrator who confirmed that they are aware that reports must be submitted to the licensing agency and the resident’s responsible party no later than seven (7) days following the occurrence of the incident. LPA informed the Administrator that they were recently cited for a violation of CCR 87211(a)(1) on 04/29/2025. LPA informed the Administrator that this is a repeat violation of the same regulation within a twelve (12) month period. LPA informed the Administrator that a civil penalty in the amount of $250 is being assessed on today’s date (07/21/2025) for a repeat violation.

The following deficiencies and civil penalties 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.

NAME OF LICENSING PROGRAM MANAGER: Kasandra Lopez
NAME OF LICENSING PROGRAM ANALYST: Trevor Byrne
LICENSING PROGRAM ANALYST 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
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/21/2025 04:25 PM - It Cannot Be Edited


Created By: Trevor Byrne On 07/21/2025 at 03:46 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: 07/21/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/04/2025
Section Cited
CCR
87463(f)

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(f) The licensee shall immediately, or as soon as reasonably possible, communicate...the recommendation...of the appropriate licensed medical professiona...Documentation...shall be added to the resident’s record.This requirement is not met as evidenced by:
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Administrator agreed to obtain updated medical assessments for the identified individuals and send proof of the completed medical assessment no later than POC due date.
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Based on interview and record review, the licensee did not comply with the section cited above asR1 and R2 did not have an updated medical assessment that accurately reflected their current conditions following a change in condition which poses a potential health risk to persons in care.
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Type B
08/04/2025
Section Cited
CCR87211(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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Administrator agreed to submit the incident report to licensing 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 R2's recent hospitalization was not reported to CCLD within the required timeframe 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.
Kasandra Lopez
NAME OF LICENSING PROGRAM MANAGER:
Trevor Byrne
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST 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


LIC809 (FAS) - (06/04)
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