195850438-3-20-2025-29-AS-CYEE-DEY4YJ-20250320193114

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 195850438
Report Date: 03/20/2025
Date Signed: 03/20/2025 07:31:47 PM

Document Has Been Signed on 03/20/2025 07:31 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:	SNA ASSISTED LIVING		FACILITY NUMBER:	195850438
ADMINISTRATOR/ DIRECTOR:	ASATRYAN, MARINE		FACILITY TYPE:	740
ADDRESS:	6862 KATHERINE AVENUE		TELEPHONE:	(818) 266-8090
CITY:	VAN NUYS	STATE: CA	ZIP CODE:	91405
CAPACITY: 6		CENSUS: 5	DATE:	03/20/2025
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:03 AM
MET WITH:	Armenak Saakyan, Applicant		TIME VISIT/ INSPECTION COMPLETED:	07:40 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Christine Yee conducted a scheduled Pre-licensing and Component III visit to ensure that the home meets Title 22 requirements and met with Armenak Saakyan, Applicant. The complete CARE Inspection Tool was used on today's visit The facility is a single storey family home consisting of a living room, dining room, kitchen, 4 resident bedrooms, an office/staff room, 3 full bathrooms, laundry room and a attached garage. The facility is fire cleared for 5 non-ambulatory residents and 1 bedridden resident. Bedroom #4 is approved for a bedridden resident. Garage is to be used as a garage only. All domains of the CARE Inspection Tool was reviewed on today visit. The following were observed on today's visit: The living room had the appropriate furnishing and seating for 6 residents. The front door is equipped with an auditory device The dining room had a dining table and chairs for 6 residents and 2 chairs. The sliding glass door is equipped with an auditory device. The kitchen is equipped with a refrigerator, stove, microwave and toaster. Sufficient cups, dinner plates, glasses, utensils were observed for 6 residents. Pots and pans for cooking were observed. Perishables foods for a minimum of 2 days and non-perishables foods for a minimum of 7 days were observed. Six, five gallon bottles of water were observed stored in the kitchen. Water temperature read 119.2 degrees Fahrenheit The facility has 2 fire extinguishers - one located in the kitchen and one in the dining room. Both were purchased on 6/19/24. The laundry room was observed with a washing machine and dryer. Detergents and cleaning solutions are also stored in the laundry room. Located in the room is also a full bathroom designated for staff use.

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Christine Yee
LICENSING EVALUATOR SIGNATURE:	DATE: 03/20/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2025

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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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: SNA ASSISTED LIVING	FACILITY NUMBER: 195850438
	VISIT DATE: 03/20/2025

NARRATIVE

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Bedroom #1 was observed with 2 hospital beds with full bed rails, 2 night stands, 2 lamps, a shared dresser, 2 chairs and a closet. The required bed linens were observed.
Bedroom #2 was observed with a hospital bed,a chair, a night stand, a lamp, a dresser and a closet.
Bedroom #3 was observed with a hospital bed with a full bed rail, a chair, a night stand, a lamp, a desk and a foldable picnic table. Required bed linens were observed.
Bedroom #4 was observed with 2 hospital beds, 2 chairs, 3 night stands, 2 lamps, a shared dresser and a closet. The room has a sliding glass door equipped with an auditory device. Located inside the room is a private bathroom with a shower stall, a toilet and a bath tub. Grab bars, shower chairs, slip resistant mat and a toilet riser were observed. Water temperature was tested and read 111.8 degrees Fahrenheit.
The common bathroom located by bedroom #1 is equipped with a shower stall and a toilet. Grab bars, shower chair, slip resistant mat were observed. Stored in the upper cupboards were bath towels and hand towels. No face towels were observed. Hygiene products were stored in the lower cupboards and were secured by a child safety latch. Water was tested and read 117.5 degrees Fahrenheit.
The office located by the living room is furnished with 2 sofas, a desk with a chair and a printer. Centrally stored medications and files are stored in 2 locked filing cabinets. Also stored in the room are incontinence supplies.
The facility has four combination carbon monoxide/smoke detectors. 2 are located in the resident hallway, one located in the living room and one in the office. 4 smoke detectors only were observed in each of the resident bedrooms. The interconnected carbon monoxide/smoke detectors and smoke detectors were tested and were all operational.
The first aid kit was reviewed and contained a tweezer and scissors and a thermometer. A first aid manual was observed.
The facility has internet but the new owner does not currently have a internet access device dedicated for resident use or a usage policy to ensure all residents have access to the device.
The outside was toured and a table and chairs were observed on the covered patio. The outside areas back and front were observed to be clean and well maintained except, the hose and the wiring located along the left side of the home needs to put away or discarded. The trash cans were observed to be tightly sealed.

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Christine Yee
LICENSING EVALUATOR SIGNATURE:	DATE: 03/20/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2025

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: SNA ASSISTED LIVING	FACILITY NUMBER: 195850438
	VISIT DATE: 03/20/2025

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The following corrections need to be made prior to licensure:

provide a internet access device dedicated for resident's use. The type of device should allow for privacy when being used. A usage policy needs to be developed to allow for usage by all residents.
repair the hole in the door screen on the sliding glass door in bedroom #4.
purchase face towels in sufficient quantities to allow for changing.
purchase additional linens such as fitted sheets, flat sheets and twin sized blankets to allow for changing weekly or as needed.
add an addendum to the Admission Agreement to address the retention or prohibition of fire arms at the facility
recommendation was made to review the Infection Control Plan add the details to the plan
recommendation was made to review the Emergency Disaster Preparedness plan and add details
remove the full bed rails from the right side bed in bedroom #1 and the 1/2 bed rail from the right side bed in bedroom #4 or provide evidence that the facility has obtained the appropriate physician's order and clearance to use the full and half bed rail.

The following will be completed once the facility is licensed:

General Liability insurance will be purchased when licensed
Client and Staff files will created for every staff, resident and volunteer under the new ownership
Licensee will ensure that all employees and volunteers have received a criminal record clearance and are associated to the facility prior to being present at the facility
Admissions Agreement will be completed under the new license.

COMPONENT III was also conducted with Armenak Saakyan on today's visit.

The Applicant will contact LPA Yee once the corrections are completed.

Exit interview was conducted.

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Christine Yee
LICENSING EVALUATOR SIGNATURE:	DATE: 03/20/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2025

LIC809 (FAS) - (06/04)

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