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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195850618
Report Date: 03/11/2025
Date Signed: 03/11/2025 12:18:22 PM

Document Has Been Signed on 03/11/2025 12:18 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:MY ELDERLY HOMEFACILITY NUMBER:
195850618
ADMINISTRATOR/
DIRECTOR:		TAVMASYAN, DIANAFACILITY TYPE:
740
ADDRESS:7502 BECK AVETELEPHONE:
(818) 919-6499
CITY:NORTH HOLLYWOODSTATE: CAZIP CODE:
91605
CAPACITY: 6CENSUS: 0DATE:
03/11/2025
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:43 AM
MET WITH:Dianna TavmasyanTIME VISIT/
INSPECTION COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA) Trevor Byrne conducted a pre-licensing visit to the above noted facility. The LPA met with applicant, Dianna Tavmasyan. This is a new facility application. A dementia care program was included in the plan of operation. A Hospice Waiver has been requested.

The facility is a one-story home. Beginning at 09:43 AM, a physical plant tour was conducted inside and out. An approved fire clearance was received, clearing them for five (5) non-ambulatory residents; and, one (1) bedridden resident. The facility has six (6) private resident bedrooms. All resident rooms have direct exits to the outside. All resident rooms are set up with beds, nightstands, lamps, chests of drawers, 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, 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. There are no staff rooms awake night staff only is required. All rooms were free of odors. All window screens were clean and maintained in good repair.

There are two (2) bathrooms in the hallway and one (1) private resident bathroom attached to bedroom #3. All resident bathrooms have a shower with non-skid materials. All toilets and showers have grab bars. The hot water temperature was tested in all bathrooms and the kitchen and was found to be within the range of 105*F and 120*F.

Resident and staff records are stored in a locked desk drawer which is currently located in the living room of the facility. Medications are centrally stored in a locked cabinet in the kitchen. The first aid supplies were complete, including a thermometer and a current version of a first aid manual. They were stored in a locked hallway closet. Continued on LIC 809C.
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Trevor Byrne
LICENSING EVALUATOR SIGNATURE: DATE: 03/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/11/2025
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 3
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: MY ELDERLY HOME
FACILITY NUMBER: 195850618
VISIT DATE: 03/11/2025
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Kitchen knives are stored in a locked drawer in the kitchen. Stove burners are rendered inaccessible to the residents via the use of child proofing knobs. The supply of dishes, utensils, pots, pans and drinkware is adequate. The freezer was maintained at zero degrees Fahrenheit (0*F) and the refrigerator was maintained at 40*F. The supply of nonperishable 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. Trash cans had tight fitting lids. Kitchen, laundry and house cleaning supplies are stored in a locked cabinet located in the facility hallway. 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/dining area. LPA observed cameras located throughout the common areas of the facility. LPA confirmed with applicant that audio is not recorded. There was sufficient space to accommodate both indoor and outdoor activities. Night lights were maintained in hallways and passageways to nonprivate bathrooms. Stairways, inclines, ramps and open porches and areas of potential hazard to residents with poor balance or eyesight were made inaccessible to residents unless equipped with sturdy hand railings and unless well-lighted. All ramps were secure and non-slippery and were positioned at the level where wheelchairs and walkers may enter and exit the facility safely. There is an electric fireplace heater in the living room. It is screened and there are no tools. Alarms on all exterior doors were engaged at the time of visit and 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’s combination smoke and carbon monoxide alarm system is hard wired. The smoke detector and carbon monoxide detectors were tested and functioned properly during the time of visit. There is one (1) fire extinguisher throughout the house. It is fully charged and does not exceed the expiration date.

Continued on LIC 809C.
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Trevor Byrne
LICENSING EVALUATOR SIGNATURE:

DATE: 03/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2025
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: MY ELDERLY HOME
FACILITY NUMBER: 195850618
VISIT DATE: 03/11/2025
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Hot water was tested in each bathroom, which included the resident bathrooms and all common bathrooms, in addition to the kitchen; and, the hot water ranged from 108.7 to 114.4 degrees Fahrenheit. The laundry area is located in a closet in the hallway of the facility. The supply of extra bed and bath linens is adequate. Personal hygiene items (shampoos, soaps) were adequate and are stored in each resident room. Extra incontinence supplies are stored in a hallway closet and in a storage shed located in the backyard of the facility. There is a functioning telephone on the premises. The emergency exiting plans/sketch are posted throughout the common areas of the facility and in each resident room. The emergency telephone numbers along with other required postings are posted on the wall in the dining area.

The exterior passageways were clean and clear of any obstructions. There is a covered patio area at the back of the house with tables and chairs where residents can sit. The entire property is fenced. The back and sides of the house are separated from the front yard by a gate located on the west side of the property. The gate to the driveway is moved manually. There is a door gate for persons to enter the front yard. There are two (2) locked storage sheds located in the back yard. There are not any bodies of water on the premises at the present time.

Component III (COMP III) orientation was completed with the applicant at the time of this inspection. This report will be sent to the Centralized Application Bureau (CAB). 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.
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Trevor Byrne
LICENSING EVALUATOR SIGNATURE:

DATE: 03/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2025
LIC809 (FAS) - (06/04)
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