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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195850534
Report Date: 01/05/2026
Date Signed: 01/06/2026 08:27:13 AM

Document Has Been Signed on 01/06/2026 08:27 AM - 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: 2DATE:
01/05/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:15 AM
MET WITH:Nurista MartinyanTIME VISIT/
INSPECTION COMPLETED:
04:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Trevor Byrne arrived at the facility unannounced to conduct the required annual visit at 10:15 AM. LPA met with facility staff who contacted the facility Administrator Nurista Martinyan. The Administrator arrived to the facility at 10:39 AM. Entrance interview conducted and the reason for the visit was explained.

Beginning at 10:40 AM the LPA, along with the Administrator 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:

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 the Administrator 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 contained direct exits to the outdoors of the facility. All direct exits were observed to contain functioning auditory alarms.

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. Both 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 113.2 and 113.4 degrees Fahrenheit, which is in compliance with regulation.

Continued on LIC 809C.

NAME OF LICENSING PROGRAM MANAGER: Kasandra Lopez
NAME OF LICENSING PROGRAM ANALYST: Trevor Byrne
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 01/05/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/05/2026
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.

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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: 01/05/2026
NARRATIVE
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COMMON AREAS: This included 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 contained activities for resident use and a fireplace. The fireplace was appropriately screened and contained no tools. The hallway was observed to contain storage closets which contained extra care supplies, and emergency food and water 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, along with the fire door, were tested at 11:19 AM and were functional at the time of the visit.

KITCHEN: The LPA observed the kitchen area to be clean. Kitchen appliances appeared to be in operable condition. The facility had a sufficient supply of two (2) days perishable and seven (7) days non-perishable food. LPA observed a secured lock box which contained knives and other sharp objects. Additionally, the kitchen contained a locked under-sink cabinet that contained soaps and cleaning chemicals as well as a locked cabinet that contained medications. LPA observed a fire extinguisher mounted on the wall to be purchased on 11/06/2024. LPA informed the Administrator that this was more than twelve (12) months from the inspection date. The Administrator had a new fire extinguisher purchased and installed at the time of the visit.

OUTDOOR SPACE: The facility had one (1) emergency exit gate located in the front of the facility; LPA observed clear passageways for emergency exit use. The facility had adequate shaded seating outdoors for resident use. The backyard was observed to contain a secured shed which contained care supplies and gardening supplies. LPA observed an unsecured saw blade and motor oil in the back yard of the facility. LPA informed the Administrator who secured the items at the time of the visit.

RECORD REVIEW: Record review began at 11:27 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. Four (4) staff files were reviewed. All staff files contained all required documents and trainings. Two (2) resident files were reviewed. Both resident files had admission agreements that were printed on two sides of the paper. LPA informed the Administrator that the print in the agreement shall appear on one side of the paper only. One (1) admission agreement was observed to be missing the rate for all basic services which the facility is required to provide.

Continued on LIC 809C.

NAME OF LICENSING PROGRAM MANAGER: Kasandra Lopez
NAME OF LICENSING PROGRAM ANALYST: Trevor Byrne
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 01/05/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/05/2026
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: 01/05/2026
NARRATIVE
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RECORD REVIEW CONT: Both resident files were observed to contain incomplete appraisal needs and services plans which were missing signatures. Both resident files were observed to be missing signed copies of the resident’s personal rights. Resident #1 (R1)’s bed was observed to contain full bed rails. LPA reviewed R1’s file and did not observe R1 to be enrolled with a hospice company. LPA informed the Administrator that bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails. The Administrator removed the full bed rails from R1’s bed at the time of the visit.

MEDICATION REVIEW: Medication review began at 12:50 PM. Medications for two (2) of two (2) residents were observed. R1’s medication count did not correspond with the start date listed on their centrally stored medication and destruction record (CSMDR). LPA informed the Administrator who stated that R1 came with multiple packets of their medications. LPA reviewed R1’s CSMDR and did not observe any additional packages of medications listed.

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 they pertain to infection control are adequate. Emergency disaster drills are conducted quarterly; the facility’s last emergency disaster drill was conducted in October 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. The staff member interviewed was knowledgeable on their roles and responsibilities, the resident’s rights, the forms of abuse, and the appropriate reporting procedures for suspected abuse.

During today’s visit LPA obtained a copy of the facility’s LIC 500, resident roster, and current liability insurance.

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.

NAME OF LICENSING PROGRAM MANAGER: Kasandra Lopez
NAME OF LICENSING PROGRAM ANALYST: Trevor Byrne
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 01/05/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/05/2026
LIC809 (FAS) - (06/04)
Page: 4 of 8
Document Has Been Signed on 01/06/2026 08:27 AM - It Cannot Be Edited


Created By: Trevor Byrne On 01/05/2026 at 03:34 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: 01/05/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87202(a)
Fire Clearance
(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above as the facility's fire extinguisher was last purchased on 11/06/2024 which was more than 12 months from the inspection date which posed an immediate safety risk to persons in care.
POC Due Date: 01/05/2026
Plan of Correction
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Administrator had a new fire extinguisher purchased and installed at the time of the inspection. POC cleared.
Type A
Section Cited
CCR
87309(a)
Storage Space and Access
(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above as an unsecured saw blade and bottle of motor oil were observed in the backyard of the facility which posed an immediate health and safety risk to persons in care.
POC Due Date: 01/05/2026
Plan of Correction
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4
Administrator secured the items at the time of the inspection. POC cleared.
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: 01/05/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/05/2026


LIC809 (FAS) - (06/04)
Page: 5 of 8
Document Has Been Signed on 01/06/2026 08:27 AM - It Cannot Be Edited


Created By: Trevor Byrne On 01/05/2026 at 03:34 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: 01/05/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(a)(4)
Incidental Medical and Dental Care Services
(4) The licensee shall assist residents with self-administered medications as needed.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above as R1's medication did not appear to be administered as prescribed based on R1's CSMDR and medication count not aligning appropriately which poses an immediate health risk to persons in care.
POC Due Date: 01/06/2026
Plan of Correction
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Administrator agreed to submit a statement of understanding confirming that they will log and administer medications appropriately and per doctor's orders. Administrator agreed to submit the statement no later than POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
Kasandra Lopez
NAME OF LICENSING PROGRAM MANAGER:
Trevor Byrne
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 01/05/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/05/2026


LIC809 (FAS) - (06/04)
Page: 6 of 8
Document Has Been Signed on 01/06/2026 08:27 AM - It Cannot Be Edited


Created By: Trevor Byrne On 01/05/2026 at 03:34 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: 01/05/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87463(a)
Reappraisals
(a) The pre-admission appraisal, as specified in Section 87457, Pre-Admission Appraisal, shall be updated, in writing as frequently as necessary or once every 12 months, whichever occurs first, to note significant changes in condition, as defined in Section 87101, Definitions, and to keep the appraisal accurate. For the purposes of this section, the updated pre-admission appraisal shall be referred to as the reappraisal.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above as 2 of 2 residents had incomplete appraisal needs and services plans that were missing most information included and signatures from the residents/ resident's responsible parties which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/19/2026
Plan of Correction
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Administrator agreed to submit completed appraisal needs and services plans for both residents to CCLD no later than POC due date.
Type B
Section Cited
CCR
87507(a)(1)(A)
Admission Agreements
(a) The licensee shall complete an individual written admission agreement, as defined in Section 87101(a), with each resident or the resident's representative, if any. (1) The text of the admission agreement, including any attachments and modifications, shall be: (A) Printed in black type of not less than 12-point type size, on plain white paper. The print shall appear on one side of the paper only.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above as both resident admission agreements were printed on both sides of the paper which poses a potential personal rights risk to persons in care.
POC Due Date: 01/19/2026
Plan of Correction
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Administrator agreed to copy the admission agreements to appear on one side of the page only and Administrator agreed to submit a statement of understanding confirming that they will only print admission agreements on one side of the paper for all future admissions to the facility.
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: 01/05/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/05/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/06/2026 08:27 AM - It Cannot Be Edited


Created By: Trevor Byrne On 01/05/2026 at 03:34 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: 01/05/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87608(a)(5)(B)
Postural Supports
(B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and record review, the licensee did not comply with the section cited above as R1's bed contained full bed rails and R1 was not receiving hospice services which posed a potential personal rights risk to persons in care.
POC Due Date: 01/05/2026
Plan of Correction
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2
3
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Administrator removed the full rails from R1's bed at the time of the visit. POC cleared.
Section Cited
Deficient Practice Statement
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2
3
4
POC Due Date:
Plan of Correction
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2
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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: 01/05/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/05/2026


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