195850447-1-15-2026-29-AS-CYEE-DQD2WE-20260115164524

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 195850447
Report Date: 01/15/2026
Date Signed: 01/15/2026 04:46:14 PM

Document Has Been Signed on 01/15/2026 04:46 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 FACILITY		FACILITY NUMBER:	195850447
ADMINISTRATOR/ DIRECTOR:	MKHITARYAN, EDMOND		FACILITY TYPE:	740
ADDRESS:	7460 MAMMOTH AVE		TELEPHONE:	(661) 383-3477
CITY:	VAN NUYS	STATE: CA	ZIP CODE:	91405
CAPACITY: 6		CENSUS: 0	DATE:	01/15/2026
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:17 AM
MET WITH:	Junaida Shakhvaladyan, Applicant		TIME VISIT/ INSPECTION COMPLETED:	04:45 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 subsequent announced Prelicensing and Component III visit to ensure that the deficiencies observed on the initial Prelicensing visit conducted on 10/30/2025 were corrected and to complete Component III. LPA Yee met with Junaida Shakhvaladyan, Applicant. Per tour of the home on today's visit, the following corrections were made: the queen size bed in bedroom #4 and full size bed in bedroom #2 were replaced with 2 beds in each room. another chair was placed in bedroom #2, #3 and 2 chairs were place in bedroom #4 a shared dresser was placed in bedroom #2, #3 and #4 another night stand and lamp was placed in bedroom #2 bed rails were removed from the hospital beds in bedroom #3 sufficient blankets and sets of towels were purchased in quantities to allow for changing the hardwired combination smoke/carbon monoxide detectors were placed in all the resident rooms, staff rooms, hallways, living room and dining room. All were tested individually and were operational. plenty of non-perishable foods for a minimum of 7 days were observed 13 five gallon bottles of water were observed hygiene products were observed in a locked cabinet located inside the only common bathroom. the shoe rack by the front door was relocated The fire safety plan was reviewed. continued on LIC809-C

NAME OF LICENSING PROGRAM MANAGER: Kristin Heffernan
NAME OF LICENSING PROGRAM ANALYST: Christine Yee
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 01/15/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/15/2026

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: MADDIE'S GREEN HAVEN FACILITY	FACILITY NUMBER: 195850447
	VISIT DATE: 01/15/2026

NARRATIVE

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The Applicant provided a copy of the Emergency Disaster Preparedness Plan for review. A copy was also emailed to LPA.
Chairs were added in the living room to allow seating for 6 residents
the heater wires for the wall heater mounted in bedroom #4 were removed and does not generate heat and is used decoratively.
The facility telephone - (747) 264-0754 was tested and was operational
a first aid manual was observed
the backyard was cleaned and all stored items noted on the initial report had been removed.

COMPONENT III was conducted with the Applicant on today's visit.

The Applicant was reminded to do the following once the licensing process has been completed:

purchase general liability insurance with limits of $1 million per occurrence and $3 million total annual aggregate
create files for all staff, all residents and volunteers if applicable
ensure that all staff and any persons who are required to have a criminal record clearance have obtained the clearance and have requested a criminal record transfer prior to their initial presence at the facility
notify the Department of the acceptance of the first resident within 5 days of acceptance.
purchase perishable foods for a minimum of 2 days prior to the acceptance of the first resident

As of this visit, there is no obvious corrections identified to hold up the clearance of the home.

Exit interview was conducted and a copy of the report was provided.

NAME OF LICENSING PROGRAM MANAGER: Kristin Heffernan
NAME OF LICENSING PROGRAM ANALYST: Christine Yee
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 01/15/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/15/2026

LIC809 (FAS) - (06/04)

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