<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195850612
Report Date: 05/15/2025
Date Signed: 05/15/2025 01:14:08 PM

Document Has Been Signed on 05/15/2025 01:14 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:LAUREL CANYON RESIDENTIAL CAREFACILITY NUMBER:
195850612
ADMINISTRATOR/
DIRECTOR:		HARUTYUNYAN, ARMINEFACILITY TYPE:
740
ADDRESS:8054 LAUREL CANYON BOULEVARDTELEPHONE:
(323) 505-6000
CITY:NORTH HOLLYWOODSTATE: CAZIP CODE:
91605
CAPACITY: 6CENSUS: 0DATE:
05/15/2025
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:33 AM
MET WITH:Kristine HarutyunyanTIME VISIT/
INSPECTION COMPLETED:
01:15 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 conducted a pre-licensing visit to the above noted facility at 09:33 AM. The LPA met with applicant, Kristine Harutyunyan. This is a new facility. A dementia program was included in the plan of operation. A Hospice Waiver has been requested for six (6) residents.

The facility is one story. At 09:35 AM, a physical plant tour was conducted inside and out. An approved fire clearance was received, clearing them for six (6) bedridden residents. The facility has one (1) private staff bedroom, Room #1, and three (3) shared resident rooms, Rooms #2, 3, and 4. Bedrooms #3 and 4 have direct exits to the outside. The facility is equipped with a fire sprinkler system. All resident rooms are set up with beds, nightstands, lamps, chests of drawers, chairs and closet space. The beds are furnished with box springs, comfortable mattress and clean linen; which includes, a mattress pad, top and bottom linens, pillowcases, blanket (if needed) and a bedspread. Lighting in the rooms appeared adequate. The bedrooms were large enough to allow for easy passage between the beds and furniture with a wheelchair or walker. In addition, no bedroom was used as a passageway to another room, bath or toilet. All rooms were free of odors. Bedrooms #1 was observed to have a rip in the window screen and bedroom #2 was observed to be missing a window screen.

There are two (2) bathrooms in the facility. Bathroom one (1) located next to the kitchen, is designated as a staff bathroom. The resident bathroom has a shower with non-skid materials. The toilet and shower have grab bars. The hot water temperature was tested in the bathrooms and the kitchen and was found to be within the range of 105*F and 120*F.
Continued on LIC 809C.
NAME OF LICENSING PROGRAM MANAGER: Kasandra Lopez
NAME OF LICENSING PROGRAM ANALYST: Trevor Byrne
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/15/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 5
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)
Page: 2 of 5
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: LAUREL CANYON RESIDENTIAL CARE
FACILITY NUMBER: 195850612
VISIT DATE: 05/15/2025
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
26
27
28
29
30
31
32
Resident and staff records are stored in the Administrator’s desk which is currently located in the living room. Medications are centrally stored in a locked cabinet in the kitchen. The first aid supplies are stored in the entryway and were complete, including a thermometer and a current version of a first aid manual.

Kitchen knives are stored in a locked drawer in the kitchen. Stove burners are rendered inaccessible to the residents by removing them when not in use. The supply of dishes, utensils, pots, pans and drinkware is adequate. LPA was unable to measure the temperature of the refrigerator or the freezer due to the absence of a temperature gauges. The supply of nonperishable and perishable food is adequate. There are no pesticides (poisons) or toxins stored in any food storage area or preparation area with utensils. Appliances in the kitchen were clean and all appeared functional. Kitchen, laundry and house cleaning supplies are stored in locked cabinets located under the kitchen and bathroom sinks. LPA observed the under-sink cabinet located in the staff bathroom to contain laundry chemicals and lack a locking device. No flies or other vermin were observed.

The common areas were appropriately furnished, and the lighting was adequate. There are televisions and other entertainment equipment, games and activity supplies in the living room and dining area. There was sufficient space to accommodate both indoor and outdoor activities. Night lights were maintained in hallways and passageways to nonprivate bathrooms. LPA observed the front Stairway of the facility to lack a ramp for resident access which poses a potential hazard to residents with poor balance or eyesight. One (1) ramp, connected to bedrooms #3 and 4 was secure and non-slippery and was positioned at the level where wheelchairs and walkers may enter and exit the facility safely. Alarms on all exterior doors were engaged at the time of visit and were functional. In addition, the physical plant is consistent with the submitted facility sketch/floor plan. The facility had emergency lighting, which included flashlights, or other battery powered lighting, and batteries. The facility has a furnace, which is able to heat rooms that residents occupy to a minimum of 68 degrees Fahrenheit; and, they have central air conditioning and are able to cool rooms to a comfortable range, not to exceed 85 degrees Fahrenheit.

The facility smoke alarm system is hard wired. The smoke detector, fire doors, and carbon monoxide detectors were tested at 10:07 AM and functioned properly during the time of visit.

Continued on LIC 809C.
NAME OF LICENSING PROGRAM MANAGER: Kasandra Lopez
NAME OF LICENSING PROGRAM ANALYST: Trevor Byrne
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2025
LIC809 (FAS) - (06/04)
Page: 3 of 5
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: LAUREL CANYON RESIDENTIAL CARE
FACILITY NUMBER: 195850612
VISIT DATE: 05/15/2025
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
26
27
28
29
30
31
32
There are two (2) fire extinguishers throughout the house. They are fully charged and do not exceed the expiration date.

Hot water was tested in each bathroom, which included the resident bathroom and staff bathroom, in addition to the kitchen; and, the hot water ranged from 117.0 to 118.6 degrees Fahrenheit. The laundry area is located in the staff bathroom. The supply of extra bed and bath linens is adequate. Personal hygiene items (shampoos, soaps) were adequate and are stored in a hallway closet in addition to incontinence supplies. There is a functioning telephone on the premises. LPA did not observe emergency exiting plans/sketch posted in the facility. LPA did not observe emergency telephone numbers posted in the facility. Other required postings are posted in the living room and dining area.

The exterior passageways were clean and clear of any obstructions. There is a covered patio area at the front of the house with tables and chairs where residents can sit. The entire property is fenced. An additional home with a separate address is separated from the facility by a fence and gate. The gate to the driveway is moved automatically. There is a gate for persons to enter the front yard. There is a locked storage shed in the back yard. There are not any bodies of water on the premises at the present time. The garage is not accessible from the house; the doors were not locked. LPA reminded the applicant that once they receive residents, if they store toxic or danger items or tools in the garage, it must be kept locked.

COMP III orientation was completed with the applicant during this pre-licensing inspection. The following items must be corrected prior to licensure. Submit proof of corrections, along with a copy of this report, to LPA Byrne so that your application may be completed. A follow-up inspection may be scheduled once all corrections are received to ensure compliance with regulation.

This report will be sent to the Centralized Application Bureau (CAB) once all corrections are received. You will be notified by the CAB Analyst when your license has been approved. You are not allowed to begin operating until you have been notified that your license has been approved by the CAB Analyst. Failure to comply could affect approval of your license.

Continued on LIC 809C.

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

DATE: 05/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2025
LIC809 (FAS) - (06/04)
Page: 4 of 5
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: LAUREL CANYON RESIDENTIAL CARE
FACILITY NUMBER: 195850612
VISIT DATE: 05/15/2025
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
26
27
28
29
30
31
32
87303(c)
87303 Maintenance and Operation
(c) All window screens shall be clean and maintained in good repair.

87555(b)(21)
87555 General Food Service Requirements
(b) The following food service requirements shall apply:
(21) Freezers of adequate size shall be maintained at a temperature of 0 degrees F (-17.7 degrees C), and refrigerators of adequate size shall maintain a maximum temperature of 40 degrees F (4 degrees C). They shall be kept clean and food stored to enable adequate air circulation to maintain the above temperatures.

87309(a)
87309 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.

87307(d)(4)
87307 Personal Accommodations and Services
(d) The following space and safety provisions shall apply to all facilities:
(4) Stairways, inclines, ramps and open porches and areas of potential hazard to residents with poor balance or eyesight shall be made inaccessible to residents unless equipped with sturdy hand railings and unless well-lighted.

87212(c)
87212 Emergency Disaster Plan
(c) Emergency exiting plans and telephone numbers shall be posted.
NAME OF LICENSING PROGRAM MANAGER: Kasandra Lopez
NAME OF LICENSING PROGRAM ANALYST: Trevor Byrne
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2025
LIC809 (FAS) - (06/04)
Page: 5 of 5