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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195850643
Report Date: 08/20/2025
Date Signed: 08/20/2025 12:05:10 PM

Document Has Been Signed on 08/20/2025 12:05 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:MARY'S CHATEAU ASSISTED LIVINGFACILITY NUMBER:
195850643
ADMINISTRATOR/
DIRECTOR:		TANDRETSYAN, LIANAFACILITY TYPE:
740
ADDRESS:14329 ALBERS STREETTELEPHONE:
(818) 388-9595
CITY:SHERMAN OAKSSTATE: CAZIP CODE:
91401
CAPACITY: 6CENSUS: 0DATE:
08/20/2025
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:37 AM
MET WITH:Mary Petikyan - Administrator
Manvel Minasyan - Licensee		TIME VISIT/
INSPECTION COMPLETED:
12:15 PM
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Licensing Program Analyst (LPA) Quoc Huynh conducted an announced pre-licensing visit to the above noted facility. At 9:37AM, the LPA met with applicants, Mary Petikyan and Manvel Minasyan. Entrance interview conducted.

An application to operate a Residential Facility for the Elderly was submitted on 02/25/2025. A dementia program was included in the plan of operation. A Hospice Waiver for 4 (four) has been requested. The facility's fire clearance was approved on 07/01/2025 for one (1) bedridden and five (5) non-ambulatory, with a total capacity of six (6) residents. Component II orientation was completed on 07/31/2025. Component III was completed with the applicants during today's visit. The facility is a single-story home located in Sherman Oaks. Beginning at 9:41AM, a physical plant tour was conducted. The following was observed:

KITCHEN: Knives were stored in a locked kitchen drawer. The supply of dishes, utensils, pots, pans and drinkware was adequate. The freezer was maintained at zero degrees Fahrenheit (0*F) and the refrigerator was maintained at 40*F. The supply of nonperishable foods and emergency food supply was adequate. Cleaning supplies were stored in a locked cabinet under the kitchen sink. There were no pesticides or toxins stored in any food storage area or preparation area. Appliances in the kitchen were clean and all appeared functional. Medications and files will be stored in a locked file cabinet located in the staff room.

Report Continued on LIC 809-C
NAME OF LICENSING PROGRAM MANAGER: Kristin Heffernan
NAME OF LICENSING PROGRAM ANALYST: Quoc Huynh
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 08/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/20/2025
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: MARY'S CHATEAU ASSISTED LIVING
FACILITY NUMBER: 195850643
VISIT DATE: 08/20/2025
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BEDROOMS/BATHROOMS: The facility had seven (7) bedrooms: six (6) private resident rooms and one (1) staff room. Bedrooms #3, #6, and the staff room have direct exits to the outside with Bedroom #6 approved for one (1) bedridden resident. Bedroom #1 had a screened and inoperable fireplace. Resident rooms were set up with beds, nightstands, lamps, chairs, sufficient clothing storage and closet space. The beds were furnished with box springs, comfortable mattress and clean linen, which includes, a mattress pad, top and bottom linens, pillowcases, and blanket (if needed). 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. All window screens were clean and maintained in good repair. There were five (5) bathrooms: three (3) private resident bathrooms and two (2) shared common bathrooms. The bathrooms had a shower with non-slip mats. One (1) hallway bathroom contained a laundry closet that was secured, and machines were in good condition. The toilet and shower had grab bars. The hot water temperature was tested and measured within the required range of 105*F to 120*F.

COMMON AREAS: Common areas were appropriately furnished, and the lighting was adequate. There was a television, reading materials, and/or activity supplies in the living room. There was sufficient space to accommodate both indoor and outdoor activities. All ramps were secured and non-slippery and were 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 functional. In addition, the physical plant is consistent with the submitted facility sketch/floor plan. The facility had emergency lighting, which included but not limited to flashlights. Nightlights were observed throughout the common areas. The facility had emergency food and water available. The facility has central heating and air conditioning to maintain rooms to a comfortable temperature.

Report Continued on LIC 809-C

NAME OF LICENSING PROGRAM MANAGER: Kristin Heffernan
NAME OF LICENSING PROGRAM ANALYST: Quoc Huynh
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2025
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: MARY'S CHATEAU ASSISTED LIVING
FACILITY NUMBER: 195850643
VISIT DATE: 08/20/2025
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At 10:05AM, the hardwired combination smoke and carbon monoxide detectors as well as fire doors were tested and functioned properly. The fire extinguishers throughout the facility were fully charged and purchased on 04/24/2025. The supply of extra bed and bath linens as well as personal hygiene items were adequate in the hallway closet. Extra incontinence supplies and other supplies were located outside in the locked garage storage. There was a functioning telephone on the premises. All required postings were posted near the entrance of the facility. First aid kit was observed to be complete, including a thermometer and a current version of a first aid manual.

OUTDOOR AREA: The exterior passageways were clean and clear of any obstructions. There were two (2) areas at the back of the house with tables and chairs where residents can sit. The outdoor space is property gated. There were no bodies of water on the premises at the present time. There was one (1) emergency exit that led to the front yard which contained a remote operated driveway gate and a self-latching door gate for everyday usage. The premises had a locked garage that was used as facility storage and also contained extra food with a refrigerator.

No corrections required. Exit interview conducted. A copy of the report was reviewed and provided. 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 the approval of your license.
NAME OF LICENSING PROGRAM MANAGER: Kristin Heffernan
NAME OF LICENSING PROGRAM ANALYST: Quoc Huynh
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2025
LIC809 (FAS) - (06/04)
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