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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195850534
Report Date: 03/12/2025
Date Signed: 03/12/2025 03:40:19 PM

Document Has Been Signed on 03/12/2025 03:40 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:
03/12/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:22 PM
MET WITH:Nurista MartinyanTIME VISIT/
INSPECTION COMPLETED:
03:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Trevor Byrne arrived to conduct an unannounced Case Management visit at the facility at 02:22 PM. LPA met with facility staff who contacted the facility Administrator Nurista Martinyan. The Administrator arrived to the facility at 02:28 PM. Entrance interview conducted and the reason for the visit was explained.

During an investigation into a complaint against the facility LPA interviewed the facility Administrator. The Administrator stated that upon admitting resident #1 (R1) to the facility they did not perform a pre-admission appraisal on the resident. LPA informed the Administrator of the importance of conducting pre-admission appraisals on residents. The Administrator expressed understanding and confirmed that they will conduct pre-admission appraisals on all future residents.

During the physical plant tour LPA observed the facility's front door to be equipped with an auditory alarm. LPA observed the alarm to be switched off. During an interview with staff #1 (S1) they revealed that on 03/01/2025 a resident eloped from the facility. S1 stated that they turned off the alarm in the morning and did not hear R1 leave the facility. LPA informed the Administrator of the importance of auditory alarms being functional and active. The Administrator expressed understanding and confirmed that auditory alarms would remain active.

The following deficiencies were cited (refer to LIC 809D). 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: 03/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/12/2025
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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Document Has Been Signed on 03/12/2025 03:40 PM - It Cannot Be Edited


Created By: Trevor Byrne On 03/12/2025 at 03:16 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: 03/12/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/26/2025
Section Cited
CCR
87457(c)

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87457 Pre-Admission Appraisal
(c) Prior to admission a determination of the prospective resident's suitability for admission shall be completed...
This requirement is not met as evidenced by:
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Licensee will submit a statement confirming that they understand the importance of conducting pre-admission appraisals and stating that they will not admit future residents without conducting a pre-admission appraisal. Licensee will submit proof of corrections no later than POC due date.
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Based on interview the licensee did not comply with the section cited above as the Administrator admitted that a pre-admission appraisal was not completed for R1 which poses a potential health, safety, or personal rights risk to clients in care.
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Type B
03/26/2025
Section Cited
CCR87705(d)

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87705 Care of Persons with Dementia
(d) The licensee shall ensure that the facility has an auditory device or other staff alert feature to monitor exits on exterior doors and perimeter fence gates...
This requirement is not met as evidenced by:
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Licensee will submit their plan on how they will ensure auditory alarms remain on and active at all times. Licensee will install an auditory alarm on the exterior gate to the facility. Licensee will submit proof of corrections to CCLD no later than POC due date.
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Based on observation and interview the licensee did not comply with the section cited above as the front door auditory alarm was turned off and not activated during inspection and on 03/01/2025 which poses a potential safety 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: 03/12/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/12/2025


LIC809 (FAS) - (06/04)
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