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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195850534
Report Date: 03/07/2025
Date Signed: 03/07/2025 01:41:16 PM

Document Has Been Signed on 03/07/2025 01:41 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:COMPLETE HARMONY BOARD AND CARE INCFACILITY NUMBER:
195850534
ADMINISTRATOR/
DIRECTOR:		MARTINYAN,NURITSAFACILITY TYPE:
740
ADDRESS:14912 GILMORE STTELEPHONE:
(818) 425-2317
CITY:VAN NUYSSTATE: CAZIP CODE:
91411
CAPACITY: 6CENSUS: 5DATE:
03/07/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:56 AM
MET WITH:Nurista MartinyanTIME VISIT/
INSPECTION COMPLETED:
01:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Trevor Byrne arrived to the facility to conduct an unannounced Case Management- Deficiencies inspection at 09:59 AM.

During today’s visit LPA conducted a physical plant tour, conducted a file review for five (5) residents, conducted a medication review for one (1) resident, interviewed the facility Administrator, one (1) staff member, and four (4) of five (5) residents.

Two (2) residents interviewed stated that they believe they are not getting the care they need at the facility. One (1) resident interviewed, Resident #1 (R1) stated that Staff #1 (S1) is unable to communicate in English and this causes discrepancies in the food they are served due to their dietary restrictions and in the administration of their medications. R1 stated that they had previously requested a copy of their Medication Administration Record (MAR) from the facility to verify the accuracy of the medications they are given and facility staff failed to provide the document. R1 stated that they have requested the facility to move them from their current room due to disagreements with their roommate and the facility has refused to move them. R1 stated that there are no activities offered at the facility and their health has declined as a result of the lack of physical activities.

The facility Administrator and staff #2 (S2) stated that S1 utilizes Google translate to communicate with residents and understands English well. S2 and the Administrator stated that facility staff observe dietary restrictions of residents and administer medications as prescribed. The Administrator and S2 were unsure if staff failed to provide R1 with a copy of their MAR. The Administrator stated that at the moment the facility has no open beds to move R1 to but stated that they would move R1 from their room when a bed becomes available. The Administrator agreed to interview residents and incorporate activities that interest the facility’s residents.
Continued on LIC 809C.

SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Trevor Byrne
LICENSING EVALUATOR SIGNATURE: DATE: 03/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/07/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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: COMPLETE HARMONY BOARD AND CARE INC
FACILITY NUMBER: 195850534
VISIT DATE: 03/07/2025
NARRATIVE
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During the file review LPA observed R1’s resident #3's (R3) file to be missing from the facility.

During medication review LPA observed R1’s MAR to not be filled out and no record of medication’s administrations were logged.

Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D): Exit interview conducted and copy of the report was issued and appeal rights provided.

SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Trevor Byrne
LICENSING EVALUATOR SIGNATURE:

DATE: 03/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2025
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Document Has Been Signed on 03/07/2025 01:41 PM - It Cannot Be Edited


Created By: Trevor Byrne On 03/07/2025 at 12:52 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: COMPLETE HARMONY BOARD AND CARE INC
FACILITY NUMBER: 195850534

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/07/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/21/2025
Section Cited
CCR
87468.2(a)(5)

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87468.2 Additional Personal Rights...
(a) ...residents shall have all of the following personal rights:
(5) To be served food...necessary to meet their nutritional needs.
This requirement is not met as evidenced by:
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Licensee will submit their plan on how they will meet the identified resident's dietary needs and a statement of understanding confirming that they understand the importance of following resident's dietary restrictions to CCLD no later than POC due date.
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Based on interview the licensee did not comply with the section cited above as one resident stated that they have been fed food which they are allergic to which poses a potential health risk to clients in care
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Type B
03/21/2025
Section Cited
CCR87468.2(a)(7)

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87468.2 Additional Personal Rights...
(a) In addition...shall have..the... rights:
(7) ...The licensee shall provide necessary information and support to ensure that residents direct the planning of their care...
This requirement is not met as evidenced by:
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The licensee will submit a statement of understanding confirming that they understand the importance of including residents in the planning of their care needs and providing residents the nessicary information to plan their care needs to CCLD no later than POC due date.
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Based on interview the licensee did not comply with the section cited above as one resident stated that they were not provided with access to their MAR to know what medications they were taking which poses a potential 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.
SUPERVISOR'S NAME:Kasandra Lopez
LICENSING EVALUATOR NAME:Trevor Byrne
LICENSING EVALUATOR SIGNATURE:
DATE: 03/07/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/07/2025


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Document Has Been Signed on 03/07/2025 01:41 PM - It Cannot Be Edited


Created By: Trevor Byrne On 03/07/2025 at 01:01 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: COMPLETE HARMONY BOARD AND CARE INC
FACILITY NUMBER: 195850534

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/07/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/21/2025
Section Cited
CCR
87465(a)(6)

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87465 Incidental Medical and Dental...
(a) ... by compliance with the following:
(6) ... a record of dosages of medications which are centrally stored shall be maintained by the facility.
This requirement is not met as evidenced by:
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Licensee will submit their plan on how they will ensure resident's MARs are complete and accurately filled out to CCLD no later than POC due date.
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Based on record review the licensee did not comply with the section cited above as one resident's MAR was observed to not be filled out and missing administrations of medications which poses a potential health risk to clients in care
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Type B
03/21/2025
Section Cited
CCR87506(a)

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87506 Resident Records
(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility...
This requirement is not met as evidenced by:
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Licensee will submit a completed resident files for R1 and R3 no later than POC due date.
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Based on record review the licensee did not comply with the section cited above as two resident's file was observed to be missing from the facility which poses a potential 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.
SUPERVISOR'S NAME:Kasandra Lopez
LICENSING EVALUATOR NAME:Trevor Byrne
LICENSING EVALUATOR SIGNATURE:
DATE: 03/07/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/07/2025


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Document Has Been Signed on 03/07/2025 01:41 PM - It Cannot Be Edited


Created By: Trevor Byrne On 03/07/2025 at 01:30 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: COMPLETE HARMONY BOARD AND CARE INC
FACILITY NUMBER: 195850534

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/07/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/21/2025
Section Cited
CCR
87219(a)

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87219 Planned Activities
(a) Residents shall be encouraged to maintain and develop their quality of life through participation in a variety of planned activities....
This requirement is not met as evidenced by:
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The licensee will submit their plan on how they will incorporate activities residents are interested in to CCLD no later than POC due date.
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Based on interview the licensee did not comply with the section cited above as residents stated that activities are not offered at the facility which poses a potential 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.
SUPERVISOR'S NAME:Kasandra Lopez
LICENSING EVALUATOR NAME:Trevor Byrne
LICENSING EVALUATOR SIGNATURE:
DATE: 03/07/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/07/2025


LIC809 (FAS) - (06/04)
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