<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195850447
Report Date: 10/30/2025
Date Signed: 10/30/2025 07:10:20 PM

Document Has Been Signed on 10/30/2025 07:10 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:MADDIE'S GREEN HAVEN FACILITYFACILITY NUMBER:
195850447
ADMINISTRATOR/
DIRECTOR:		MKHITARYAN, EDMONDFACILITY TYPE:
740
ADDRESS:7460 MAMMOTH AVETELEPHONE:
(661) 383-3477
CITY:VAN NUYSSTATE: CAZIP CODE:
91405
CAPACITY: 6CENSUS: 0DATE:
10/30/2025
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Junaida Shakhvaladyan, ApplicantTIME VISIT/
INSPECTION COMPLETED:
07:10 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 an announced Prelicensing and Component III visit to ensure that the home meets Title 22 requirements. The CARE Inspection Tool was used to conduct the visit. LPA Yee met with Junaida Shakhvaladyan, Applicant.

The home is a single storey family home consisting of a living room, dining room, kitchen, 4 bedrooms of which one is designated for live-in staff, 3 full bathrooms and a attached garage. The facility is fire cleared for 5 NON-AMBULATORY and 1 BEDRIDDEN residents.

On today's visit, LPA Yee reviewed all 12 domains of the CARE Inspection Tool, reviewed the Emergency and Disaster Plan, Residential Infection Control Plan and toured the entire physical plant, inside and outside.
The following were observed:
  • The living room is furnished with a sofa, 2 armchairs, 2 coffee tables, a wall mounted television and a television stand. Additional seating is needed. The fire place is made inaccessible by a fire screen.
  • The dining room is furnished with a long table and six chairs, a buffet table, 2 plant stands with potted plants and the centrally stored medication cart.
  • The kitchen is equipped with a stove, dishwasher, refrigerator, microwave, air fryer and a toaster oven. There are sufficient dinner plates, salad bowls, glasses, cups, soup bowls, knives, forks and spoons. Pots and fry pans were observed. There were no perishable foods purchased. Non-perishable foods were observed in the attached garage but were not in quantities to last for 7 days. Knives are stored in a


continued on LIC809-C
NAME OF LICENSING PROGRAM MANAGER: Kristin Heffernan
NAME OF LICENSING PROGRAM ANALYST: Christine Yee
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 10/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/30/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 5
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)
Page: 2 of 5
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: MADDIE'S GREEN HAVEN FACILITY
FACILITY NUMBER: 195850447
VISIT DATE: 10/30/2025
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
26
27
28
29
30
31
32
Page 2.
  • locked cabinet and dish soap and cleaning supplies are stored in a locked cabinet under the kitchensink. Laundry detergent and additional cleaning solutions are stored in a locked cabinet in the garage. Also located in the kitchen is a round table with 4 dining chairs and a fire extinguisher purchased on 6/25/25. The facility has a second fire extinguisher that is not currently mounted.
  • Bedroom #1, located by the front door is designated for staff use. It is furnished with a full size bed, a night stand a lamp, a built in closet, a desk and a coffee table.
  • Bedroom #2 is furnished with a full size bed, a night stand, a chair, 1 night stand, a lamp, a built in closet and a mounted television. The required linens were observed except for a blanket. Located inside the bedroom is a bathroom equipped with a walk-in shower, a toilet and a single sink vanity. Grab bars were observed in the shower and on the wall directly by the shower. A grab bar is needed by the toilet. A slip resistant mat was observed The water temperature was taken and it read 114.2 degrees Fahrenheit. Blinds were observed on the 2 windows.
  • Bedroom #3 is furnished with 2 hospital beds with half bed rails, 1 chair, 2 lamps, a built in closet and a sliding glass door. Located outside is a ramp. A auditory device was mounted on the door. Bed linens were observed but there was no blanket.
  • The common bathroom is equipped with a bath tub/shower, a toilet, single sink vanity and storage cabinets. Grab bars and a slip resistant mat were observed. Water temperature was tested and read 112.6 degrees Fahrenheit.
  • Bedroom #4 is furnished with a queen sized bed, 2 night stands, 2 lamps, connected armchairs, a walk in closet and a wall heater. Located inside is a bathroom equipped with a shower stall, a toilet, a single sink vanity and a large jacuzzi tub.. Grab bars and a slip resistant mat were observed in the shower and by the toilet. The water temperature was tested and read 106.5 degrees Fahrenheit.
  • The linen closet was observed with 7 sets of towels, 6 sets of twin sheets.
  • The first aid kit was observed with the appropriate gauze, salves, bandages, tweezers, scissors and thermometer. No first aid manual was observed.
  • All the windows had blinds for privacy and the screens were observed to be in good condition.


continued on LIC809-C
NAME OF LICENSING PROGRAM MANAGER: Kristin Heffernan
NAME OF LICENSING PROGRAM ANALYST: Christine Yee
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2025
LIC809 (FAS) - (06/04)
Page: 3 of 5
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: MADDIE'S GREEN HAVEN FACILITY
FACILITY NUMBER: 195850447
VISIT DATE: 10/30/2025
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
26
27
28
29
30
31
32
Page 3
  • The smoke detectors were tested individually and were operational except for the smoke detector located by the front door. The smoke detector was missing.
  • The attached garage houses the washer and dryer and is primarily used for storage. The 2 non-operational refrigerators need to be discarded.
  • The backyard has a covered patio furnished with plenty of chairs and a table. Also located in the back is a free standing gazebo equipped with benches and barbecue grills and directly adjacent to the gazebo are additional chairs. 2 storage sheds were observed. Ladders, hoyer lift, swing set, wood, cleaning buckets, mops were stored in the back and along the side of the home. Otherwise the back yard was observed to be clean
  • The front yard was also observed to be clean but the water hose needs to be rolled up.


The following corrections need to be addressed prior to licensure:
  • the queen size bed in bedroom #4 and full size bed in bedroom #2 needs to be replaced with 4 individual beds.
  • A chairs needs to be placed in bedroom #2, #3 and 2 chairs in bedroom #4
  • a dresser is needed in bedroom #2, #3 and #4
  • a night stand in bedroom #2
  • remove bed rails from the 2 hospital beds in bedroom #3
  • purchase blankets and sets of towels in quantities to allow for changing weekly or as needed.
  • purchase a carbon monoxide detector, if smoke detectors are not combination carbon/smoke detectors.
  • replace the smoke detector by the front door.
  • purchase additional non-perishable foods for a minimum of 7 days
  • purchase hygiene products.
  • remove the shoe rack located by the front door.
  • complete a fire safety plan
  • review and revise the Emergency Disaster Preparedness Plan


continued on LIC809-C
NAME OF LICENSING PROGRAM MANAGER: Kristin Heffernan
NAME OF LICENSING PROGRAM ANALYST: Christine Yee
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2025
LIC809 (FAS) - (06/04)
Page: 5 of 5
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: MADDIE'S GREEN HAVEN FACILITY
FACILITY NUMBER: 195850447
VISIT DATE: 10/30/2025
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
26
27
28
29
30
31
32
Page 4.
  • add additional seating in the living room for 6 residents
  • secure and make the wall heater inaccessible to the residents
  • purchase a telephone for the facility and ensure the telephone is operational
  • purchase a first aid manual that is approved by the American Red Cross
  • discard or store the ladders, buckets, mops, exercise equipment stored out in the back and along the side of the home and roll up the garden hose in the front


Applicant to notify LPA Yee once the corrections have been completed, but longer than 11/6/25 to schedule a second visit to clear the home.

COMPONENT III was not conducted on today's and will be scheduled on the return visit.


Exit interview was conducted.
NAME OF LICENSING PROGRAM MANAGER: Kristin Heffernan
NAME OF LICENSING PROGRAM ANALYST: Christine Yee
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2025
LIC809 (FAS) - (06/04)
Page: 4 of 5