195850534-5-1-2025-29-AS-TBYE-DG9TD3-20250501143740

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 195850534
Report Date: 05/01/2025
Date Signed: 05/01/2025 02:37:58 PM

Document Has Been Signed on 05/01/2025 02:37 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 INC		FACILITY NUMBER:	195850534
ADMINISTRATOR/ DIRECTOR:	MARTINYAN,NURITSA		FACILITY TYPE:	740
ADDRESS:	14912 GILMORE ST		TELEPHONE:	(818) 425-2317
CITY:	VAN NUYS	STATE: CA	ZIP CODE:	91411
CAPACITY: 6		CENSUS: 2	DATE:	05/01/2025
TYPE OF VISIT:	Post Licensing	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	10:07 AM
MET WITH:	Nurista Martinyan		TIME VISIT/ INSPECTION COMPLETED:	02:45 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) Trevor Byrne arrived at the facility unannounced to conduct a post-licensing visit at 10:07 AM. LPA met with facility staff who contacted the facility Administrator Nurista Martinyan. The Administrator arrived to the facility at 10:52 AM. Entrance interview conducted and the reason for the visit was explained. Beginning at 10:10 AM the LPA, along with staff #1 (S1) toured the physical plant areas inside and outside to ensure there are no health and safety hazards and that facility is in compliance with Title 22 Regulations. The following was observed: KITCHEN: The LPA observed the kitchen area to be clean. Kitchen appliances appeared to be in operable condition. The facility has a sufficient supply of two (2) days perishable and seven (7) days non-perishable food. LPA observed a secured lock box to contain knives and other sharp objects. LPA observed a fire extinguisher mounted on the wall to be purchased on 11/06/2024. The kitchen contained a locked under-sink cabinet that soaps and cleaning chemicals as well as a locked cabinet that contained medications. Continued on LIC 809C.

NAME OF LICENSING PROGRAM MANAGER: Kasandra Lopez
NAME OF LICENSING PROGRAM ANALYST: Trevor Byrne
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/01/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2025

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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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: COMPLETE HARMONY BOARD AND CARE INC	FACILITY NUMBER: 195850534
	VISIT DATE: 05/01/2025

NARRATIVE

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COMMON AREAS: This includes the living room, hallway, and dining area. LPA observed the living room to be clean and properly furnished at the time of the visit. The living room contains activities for resident use and a fireplace, it is appropriately screened and contains no tools. The hallway was observed to contain a storage closet which contained extra care supplies. The dining area was observed to be equipped with adequate seating for resident use. All furniture throughout the facility was observed to be clean and in good repair. The facility’s combination fire and carbon monoxide alarms were tested at 01:42 PM and were functional at the time of the visit. All exits in the facility were observed to contain functioning auditory alarms.

BEDROOMS: There are four (4) bedrooms in the facility; two (2) are single occupancy resident rooms and two (2) are dual occupancy resident rooms. LPA and S1 toured all four (4) resident bedrooms. All resident rooms were observed to be furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting. Bedrooms #1 and #2 contain direct exits to the outdoors of the facility.

BATHROOMS: There are two (2) bathrooms at the facility. One (1) is designated as a private resident bathroom, and one (1) is designated as a shared/common resident bathroom. All resident bathrooms were observed to be clean and were equipped with nonskid surfaces. Grab bars were observed near resident toilets and were properly secured. The water temperature was measured to be between 113.5 and 116.6 degrees Fahrenheit, which is in compliance with regulation.

OUTDOOR SPACE: The facility has one (1) emergency exit gate located in the front of the facility; LPA observed clear passageways for emergency exit use. The facility has adequate shaded seating outdoors for resident use.

RECORD REVIEW: Record review began at 10:57 AM. Staff and resident records were reviewed for documents including, but not limited to: health screening, TB test, staff training records, fingerprint clearance, resident physician's report, needs and service appraisal, consent forms, and personal rights. Two (2) staff files were reviewed. All staff files contained all required documents and trainings. Two (2) current resident files and three (3) former resident files were reviewed. The two (2) current resident files contained all required documentation and signatures. No deficiencies were observed during file review.

Continued on LIC 809C.

NAME OF LICENSING PROGRAM MANAGER: Kasandra Lopez
NAME OF LICENSING PROGRAM ANALYST: Trevor Byrne
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/01/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2025

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: COMPLETE HARMONY BOARD AND CARE INC	FACILITY NUMBER: 195850534
	VISIT DATE: 05/01/2025

NARRATIVE

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MEDICATION REVIEW: Medication review began at 12:50 PM. Medications for two (2) of two (2) residents were observed. All medications were stored properly and were appropriately documented on their respective centrally stored medication and destruction record sheets. No deficiencies were observed during medication review.

INFECTION CONTROL/EMERGENCY DISASTER PLANNING: During today’s visit, the LPA reviewed the
facility's infection control practices and the facility's emergency disaster plan. The facility’s policies and procedures as it pertains to infection control are adequate. Emergency disaster drills are conducted quarterly; the facility’s last emergency disaster drill was conducted on 04/15/2025. The facility’s emergency disaster plan is up to date and is adequate. Both the infection control plan and the emergency disaster plan are reviewed/updated annually by the facility’s Administrator.

INTERVIEWS: LPA interviewed one (1) resident. The resident interviewed stated that the staff treat them well and are attentive to their needs. The resident had no concerns with the facility. LPA interviewed one (1) staff member and the facility’s Administrator. The staff member was knowledgeable on their roles and responsibilities, the resident’s rights, the forms of abuse, and the appropriate reporting procedures for suspected abuse. During the interview S1 informed LPA that the facility recently had three (3) residents pass away in April. LPA reviewed the facility E-file and did not observe death reports submitted for the three residents. LPA reviewed the deceased residents’ files and observed the dates they passed away to be 04/18/2025, 04/23/2025, and 04/24/2025. LPA interviewed the Administrator and asked why no death reports were submitted to Community Care Licensing Division (CCLD). The Administrator stated that they had attempted to fax the documents multiple times. LPA informed the Administrator that during the visit between 11:14 AM and 11:51 AM they received the three faxed death reports. The Administrator was unable to provide LPA with proof of the death reports being faxed prior to today's insection (05/01/2025). LPA informed the Administrator that all incident and death reports must be submitted to CCLD no later than seven (7) days following the event.

During today’s visit LPA obtained a copy of the facility’s LIC 500, resident roster, and current liability insurance. The Administrator had to leave the facility during the visit but has designated S1 to sign this report on their behalf. This report was read to the Administrator via telephone call. Pursuant to Title 22 of the CA Code of Regulations, the following deficiency was cited (refer to LIC 809-D): Exit interview conducted and copy of the report was issued and appeal rights provided.

NAME OF LICENSING PROGRAM MANAGER: Kasandra Lopez
NAME OF LICENSING PROGRAM ANALYST: Trevor Byrne
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/01/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 05/01/2025 02:37 PM - It Cannot Be Edited

Created By: Trevor Byrne On 05/01/2025 at 01:50 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: 05/01/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87211(a)(1)

Reporting Requirements

(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview and record review, the licensee did not comply with the section cited above as two resident death reports were submitted to CCLD outside of the seven day required timeframe which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/15/2025
	Plan of Correction
1 2 3 4	Licensee submitted the death reports at the time of the visit. The Administrator verbally confirmed that all incident reports and death reports will be submitted to CCLD within the seven day due date window.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Kasandra Lopez
NAME OF LICENSING PROGRAM MANAGER:

	Trevor Byrne
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/01/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2025

LIC809 (FAS) - (06/04)

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