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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 195850421
Report Date: 07/24/2025
Date Signed: 07/24/2025 03:04:49 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
07/21/2025 and conducted by Evaluator Trevor Byrne
COMPLAINT CONTROL NUMBER: 29-AS-20250721113124
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:
07/24/2025
UNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Meri TarposhyanTIME COMPLETED:
03:15 PM
ALLEGATION(S):
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Facility Staff did not safeguard a resident's personal belongings
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Trevor Byrne conducted an unannounced complaint investigation visit at the facility at 09:30 AM. LPA met with staff #1 (S1) who contacted the facility Designee Meri Tarposhyan. The Designee arrived to the facility at 10:18 AM. Entrance interview was conducted and the reason for the visit was explained.

During today’s visit LPA conducted a physical plant tour, collected copies of pertinant documentation, conducted interviews with the Designee, one (1) staff member, one (1) witness, and two (2) residents between 10:15 AM and 01:00 PM.

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

DATE: 07/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2025
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-20250721113124
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: 07/24/2025
NARRATIVE
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The allegation of “Facility Staff did not safeguard a resident's personal belongings.” alleges that resident #1 (R1)’s two (2) pairs of Levi jeans, five (5) long sleeved shirts, two (2) robes, and a pair of black Velcro sneakers that they arrived to the facility with are now missing. Additionally, the allegation alleges that a suede jacket was washed improperly and ruined by facility staff. LPA reviewed R1’s file and reviewed their signed personal property and valuables sheet. LPA observed this sheet to be signed by both Resident #1 (R1) and the facility Administrator. LPA observed this sheet to indicate that R1 arrived to the facility with two (2) pants, nine (9) t-shirts, three (3) outerwear, two (2) underwear, and six (6) socks. LPA did not observe the property and valuables sheet to contain robes, long sleeved shirts, or sneakers. LPA observed R1’s closet and observed eight (8) t-shirts. Additionally, LPA observed R1 wearing one (1) t-shirt. LPA did not observe any additional clothing items in R1’s closet. LPA interviewed the Administrator, the Designee, and S1. All three (3) staff interviewed did not know where the outerwear, underwear, or socks were located. The Administrator confirmed that the two pairs of jeans were rendered unwearable following accidents and were subsequently discarded. The Administrator and Designee stated that they are in the process of replacing the pants and they should be arriving Sunday (07/27/2025). LPA interviewed Witness #1 (W1) who stated that they were in control of R1’s suede jacket. W1 confirmed that the jacket never resided at the facility and was not ruined in the laundry. During today's visit LPA was provided with copies of receipts showing the order of two (2) pairs of Levi Jeans and men's boxers tare o be delivered Sunday (07/27/2025). Based on the information obtained during interviews there is sufficient evidence to support the allegation of “Facility Staff did not safeguard a resident's personal belongings.” 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: 07/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2025
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
07/21/2025 and conducted by Evaluator Trevor Byrne
COMPLAINT CONTROL NUMBER: 29-AS-20250721113124

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:
07/24/2025
UNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Meri TarposhyanTIME COMPLETED:
03:15 PM
ALLEGATION(S):
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The facility telephone is inoperable
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Trevor Byrne conducted an unannounced complaint investigation visit at the facility at 09:30 AM. LPA met with staff #1 (S1) who contacted the facility Designee Meri Tarposhyan. The Designee arrived to the facility at 10:18 AM. Entrance interview was conducted and the reason for the visit was explained.

During today’s visit LPA conducted a physical plant tour, collected copies of pertinant documentation, conducted interviews with the Designee, one (1) staff member, one (1) witness, and two (2) residents between 10:15 AM and 03:00 PM.

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

DATE: 07/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2025
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-20250721113124
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: 07/24/2025
NARRATIVE
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The allegation of “The facility telephone is inoperable” alleges that the facility does not have a working telephone for resident use. LPA conducted a physical plant tour and observed an iPhone that is designated as the facility’s telephone for resident use. LPA observed the telephone to be charged and the telephone appeared functional. LPA made a call to the telephone and confirmed proper function of the device. LPA interviewed S1. S1 was knowledgeable on the resident’s rights and confirmed that they were aware of the resident’s rights to utilize the facility telephone. S1 stated that if calls are received on the phone they will hand the telephone to the resident and provide them privacy while they speak. LPA interviewed the Administrator who confirmed that the facility telephone is always present at the facility and is available for resident use upon request. During today’s visit LPA observed resident #1 (R1) to request to use the facility phone. LPA observed S1 immediately providing the phone to R1 for use. Resident #2 (R2) was interviewed and had no concerns about access to the facility phone. Although the allegation may have happened or is valid there is insufficient evidence to support the allegation of, “The facility telephone is inoperable.” 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: 07/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 29-AS-20250721113124
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: 07/24/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/07/2025
Section Cited
HSC
1569.153
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§1569.153 Theft and loss program... ...The program shall include...
(d)...Subsequent items brought into or removed from the facility shall be added to or deleted from the personal property inventory by the facility...
This requirement is not met as evidenced by:
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Administrator provided proof that they have ordered the missing pants and underwear. Designee agreed to submit a statement of understanding confirming that they understand the importance of safeguarding personal property and valuables and the importance of logging removed items.
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Based on interview and record review the licensee did not comply with the section cited above as 3 outerwear, 6 socks, and 2 underwear were not at the facility and were not listed as removed from the resident's property list which poses a potential personal rights risk to clients in care.
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Designee agreed to submit the statement of understanding no later than POC due date.
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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: 07/24/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5