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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195850620
Report Date: 06/12/2025
Date Signed: 06/12/2025 02:19:32 PM

Document Has Been Signed on 06/12/2025 02:19 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:COVELLO ASSISTED LIVINGFACILITY NUMBER:
195850620
ADMINISTRATOR/
DIRECTOR:		BAREGHAMYAN, ELENFACILITY TYPE:
740
ADDRESS:15447 COVELLO STREETTELEPHONE:
(213) 706-1995
CITY:VAN NUYSSTATE: CAZIP CODE:
91406
CAPACITY: 6CENSUS: 0DATE:
06/12/2025
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:30 AM
MET WITH:Gevork KharatianTIME VISIT/
INSPECTION COMPLETED:
01:55 PM
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Licensing Program Analyst (LPA) Sandra Urena conducted a Pre-licensing visit and met with the Applicant Gevork Kharatian. This is a new facility application for a Residential Facility for the Elderly (RCFE) for six (6) non-ambulatory residents; one (1) of which may be a bedridden resident(s). Fire Clearance was approved on 05/01/2025. Bedridden was approved in either bedroom #1 or #2.

At 10:45 a.m., the LPA, and the applicant toured the physical plant areas inside and outside to ensure there are no health and safety hazards and that the facility will be following Title 22 Regulations.

COMMON AREAS: The common areas include the living room area, dining room area and sun room. The living room area is equipped with appropriate furniture. There is a dedicated area for the posting of required documents at the entrance of the facility and the wall between bedroom #2 and the sun room sliding door. The Applicant will obtain a CCL Poster (If You See Something, Say Something) that meets the department’s size regulation and will replace the current poster. The poster will be place by the entrance door next to the Ombudsman poster. Smoke and carbon monoxide alarms were tested and functional at the time of the visit. Medications will be stored in a locked cabinet by the foyer area. The residents’ and staff files will be stored and locked in a file cabinet located in the storage room next to the kitchen. The fireplace was observed to be non-functional and covered with a fire screen that is bolted to the wall.
LAUNDRY AREA: The washer and dryer are located in a storage area located adjacent to the kitchen area. Detergents and cleaning supplies will be stored on a shelf on top of the washer and dryer.

Continues on LIC 809C...
NAME OF LICENSING PROGRAM MANAGER: Kasandra Lopez
NAME OF LICENSING PROGRAM ANALYST: Sandra Urena
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 06/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/12/2025
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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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: COVELLO ASSISTED LIVING
FACILITY NUMBER: 195850620
VISIT DATE: 06/12/2025
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KITCHEN: Kitchen knives are stored locked and inaccessible in a locked kitchen drawer. A seven-day supply of non-perishable food was available. The supply of dishes is adequate. Appliances in the kitchen were clean and all appeared functional. Kitchen cleaning supplies will be stored and locked under the kitchen sink. Hot water temperature was recorded at 118.6 degrees Fahrenheit. Trash cans have a tight-fitting lid. There were no pesticides or toxins stored near food, or preparation area. The first aid supplies were complete, including a thermometer and a current version of a first aid manual. A fire extinguisher is located next to the dining room table. The fire extinguisher was purchased on 06/12/2025.

BEDROOMS: There are three (3) bedrooms for residents in care. Rooms # 1 was approved as a shared room for two (2) ambulatory residents. Room #2 was approved as a shared room for one (1) bedridden resident, and one (1) non-ambulatory. Room # 3 was approved as shared bedroom for two (2) non-ambulatory residents/ and or a bedridden resident. All bedrooms were supplied with all required linens. There is sufficient lighting. The following deficiencies will be corrected per the Applicant: Bedspreads/comforted for all beds. A minimum of eight cubic feet of drawer space will be provided for all bedrooms. Smaller night stands will be purchased to allow for ample room in bedrooms #2 and #3. Chairs for all bedrooms are on route to be delivered.



BATHROOMS: There are two (2) full bathrooms. Bathrooms are equipped with toilets and shower grab bars, and non-skid mats. There are sufficient supplies of towels, paper goods and personal hygiene supplies. Hot water delivered was at 119.6 degrees Fahrenheit. The following deficiencies need to be corrected: Install mirrors in both bathrooms, hand washing signs posted, one shower chair, one trash can with cover.

SURROUNDING GROUNDS/OUTDOOR AREA: The exterior passageways were clean. The patio is furnished with outdoor furniture for residents’ use, and shade is available. The building has a central entrance for residents and visitors. Right passageway is cleared and has a self-latching gate. The self-latching mechanism is located on the outside of the gate facing the street. There is a crawl space located on the left -hand side of the exit sun room door leading to the patio. Deficiency: The crawl space needs a cover that is flushed and covers the opening of the crawl space, so that it does not become a danger to residents in care. Area to be cleared of spider webs.


Continues on LIC 809C...
NAME OF LICENSING PROGRAM MANAGER: Kasandra Lopez
NAME OF LICENSING PROGRAM ANALYST: Sandra Urena
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/12/2025
LIC809 (FAS) - (06/04)
Page: 3 of 4
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: COVELLO ASSISTED LIVING
FACILITY NUMBER: 195850620
VISIT DATE: 06/12/2025
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ADMINISTRATION: Emergency exiting plans need to be created and posted.
  • Re-do floor plan and send to CAB to be updated.

Pre-Licensing is incomplete with deficiencies to be resolved by 06/19/2025. Follow up Pre-licensure LIC809 will be generated upon resolution.

· The Applicant will obtain a CCL Poster (If You See Something, Say Something) that meets the department’s size regulation and will replace the current poster.

· Bedspreads/comforted for all beds. A minimum of eight cubic feet of drawer space will be provided for all bedrooms. Smaller nightstands will be purchased to allow for ample room in bedrooms #2 and #3. Chairs for all bedrooms.


· Install mirrors in both bathrooms, handwashing signs posted, one shower chair, one trashcan with cover.

· The crawl space needs a cover that is flushed and covers the opening of the crawl space, so that it does not become a danger to residents in care. Area to be cleared of spiderwebs.



· Emergency exiting plans need to be created and posted.


The applicant completed Component III orientation.

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.

Exit interview was conducted and reviewed with the applicant. A copy of the report was issued.

NAME OF LICENSING PROGRAM MANAGER: Kasandra Lopez
NAME OF LICENSING PROGRAM ANALYST: Sandra Urena
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/12/2025
LIC809 (FAS) - (06/04)
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