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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197603936
Report Date: 08/14/2025
Date Signed: 08/14/2025 02:19:13 PM

Document Has Been Signed on 08/14/2025 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:JUST LIKE HOMEFACILITY NUMBER:
197603936
ADMINISTRATOR/
DIRECTOR:		ALEXSANDRA VARTAPETOVAFACILITY TYPE:
740
ADDRESS:12521 KILLION STREETTELEPHONE:
(818) 769-9955
CITY:VALLEY VILLAGESTATE: CAZIP CODE:
91607
CAPACITY: 6CENSUS: 3DATE:
08/14/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:20 AM
MET WITH:Asmik Krdanyan - CaregiverTIME VISIT/
INSPECTION COMPLETED:
02:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Quoc Huynh arrived at the facility unannounced to conduct a required annual visit at 9:20AM. The LPA met with Staff #1 (S1) and Staff #2 (S2) and explained the reason for the visit. S1 contacted Administrator Aleksandra Vartapetova who was unavailable and designated S1 to conduct the visit and sign today’s report. Entrance interview conducted.

Beginning at 9:33AM, the LPA and S1 toured the physical plant areas inside and outside to ensure there are no health and safety hazards, and facility is in compliance with Title 22 Regulations. The facility is a single story residential home. The following was observed:

COMMON AREAS: At the time of the visit, living room and dining room furniture was observed to be in good condition. The dining room had a screened and inoperable fireplace. Required postings were located on the entryway wall. The entryway hallway had two (2) closets: one (1) was locked and contained resident medications and one (1) closet contained files and storage. The facility maintained a comfortable temperature throughout the visit. The facility had a laundry room connected to the kitchen and LPA observed the machines to be in good condition.

KITCHEN: The LPA observed knives stored inaccessible in a locked drawer. Additional knives and scissors were observed in unsecured drawers and S1 secured them. Cleaning supplies were stored inaccessible and locked under the sink. Kitchen appliances were clean and in operable condition.

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: 08/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/14/2025
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 14
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 14
Document Has Been Signed on 08/14/2025 02:19 PM - It Cannot Be Edited


Created By: Quoc Huynh On 08/14/2025 at 01:05 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: JUST LIKE HOME
FACILITY NUMBER: 197603936

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/14/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87207
No licensee, officer or employee of a licensee shall make or disseminate any false or misleading statement regarding the facility or any of the services provided by the facility.

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 in 1 staff had a falsified health screening report which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/15/2025
Plan of Correction
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2
3
4
The Licensee will review regulations and submit a statement of understanding to CCLD by POC due date. The Licensee will also obtain a health screening for the 1 staff and provide it to CCLD by 08/22/2025.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
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2
3
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.
Kristin Heffernan
NAME OF LICENSING PROGRAM MANAGER:
Quoc Huynh
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/14/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/14/2025


LIC809 (FAS) - (06/04)
Page: 3 of 14
Document Has Been Signed on 08/14/2025 02:19 PM - It Cannot Be Edited


Created By: Quoc Huynh On 08/14/2025 at 01:21 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: JUST LIKE HOME
FACILITY NUMBER: 197603936

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/14/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1569.618(c)(4)
Other Provisions
(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (4) Ensure that the facility is clean, safe, sanitary, and in good repair at all times.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation and interview, the licensee did not comply with the section cited above in 1 staff had 3 medications accessible to residents which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/14/2025
Plan of Correction
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2
3
4
Staff secured their medications. POC Cleared.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
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.
Kristin Heffernan
NAME OF LICENSING PROGRAM MANAGER:
Quoc Huynh
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/14/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/14/2025


LIC809 (FAS) - (06/04)
Page: 6 of 14
Document Has Been Signed on 08/14/2025 02:19 PM - It Cannot Be Edited


Created By: Quoc Huynh On 08/14/2025 at 01:21 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: JUST LIKE HOME
FACILITY NUMBER: 197603936

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/14/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87470(c)(1)
Infection Control Requirements
(c) An Infection Control Plan shall be developed by the licensee and shall be included in the Plan of Operation required by Section 87208. (1) The Infection Control Plan shall include all of the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation, interview, record review, the licensee did not comply with the section cited above in the facility was unable to locate the infection control plan which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/21/2025
Plan of Correction
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2
3
4
The Licensee will complete the infection control plan (LIC 9282) and send it to CCLD by POC due date.
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation, the licensee did not comply with the section cited above in 1 kitchen drawer was not in good repair which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/21/2025
Plan of Correction
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2
3
4
The Licensee will have the drawer repaired and send CCLD proof by POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Kristin Heffernan
NAME OF LICENSING PROGRAM MANAGER:
Quoc Huynh
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/14/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/14/2025


LIC809 (FAS) - (06/04)
Page: 7 of 14
Document Has Been Signed on 08/14/2025 02:19 PM - It Cannot Be Edited


Created By: Quoc Huynh On 08/14/2025 at 01:21 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: JUST LIKE HOME
FACILITY NUMBER: 197603936

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/14/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(c)
Maintenance and Operation
(c) All window screens shall be clean and maintained in good repair.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in 5 windows screens were not maintained in good repair which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/28/2025
Plan of Correction
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2
3
4
The Licensee will repair and replace the window screens and send proof to CCLD by POC due date.
Type B
Section Cited
CCR
87305(a)
Alterations to Existing Buildings or New Facilities
(a) Prior to construction or alterations, all facilities shall obtain a building permit.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and interview, the licensee did not comply with the section cited above in the licensee did not notify CCLD of facility remodeling and did not obtain a permit which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/28/2025
Plan of Correction
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The Licensee will create a plan of remodeling that contains how they will mitigate the residents risk and obtain a building permit and send it to CCLD by POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Kristin Heffernan
NAME OF LICENSING PROGRAM MANAGER:
Quoc Huynh
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/14/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/14/2025


LIC809 (FAS) - (06/04)
Page: 8 of 14
Document Has Been Signed on 08/14/2025 02:19 PM - It Cannot Be Edited


Created By: Quoc Huynh On 08/14/2025 at 01:21 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: JUST LIKE HOME
FACILITY NUMBER: 197603936

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/14/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in resident restroom sinks did not measure within the required range which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/15/2025
Plan of Correction
1
2
3
4
The Licensee will adjust the water heater and send CCLD proof of the adjusted water temperature by POC due date.
Type A
Section Cited
CCR
87307(d)(6)
Personal Accommodations and Services
(6) All outdoor and indoor passageways and stairways shall be kept free of obstruction.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in the perimeter and emergency side exit was obstructed which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/15/2025
Plan of Correction
1
2
3
4
The Licensee will clear the passageways and send CCLD proof by POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Kristin Heffernan
NAME OF LICENSING PROGRAM MANAGER:
Quoc Huynh
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/14/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/14/2025


LIC809 (FAS) - (06/04)
Page: 4 of 14
Document Has Been Signed on 08/14/2025 02:19 PM - It Cannot Be Edited


Created By: Quoc Huynh On 08/14/2025 at 01:21 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: JUST LIKE HOME
FACILITY NUMBER: 197603936

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/14/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in knives, scissors, and bleach bottles were not secured which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/14/2025
Plan of Correction
1
2
3
4
Staff secured all items during the visit. POC Cleared.
Type A
Section Cited
HSC
1569.618(c)(3)
Other Provisions
(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on interview and record review, the licensee did not comply with the section cited above in 4 out of 5 staff did not have current first aid/cpr training which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/15/2025
Plan of Correction
1
2
3
4
The Licensee will obtain 4 staff's first aid/cpr training and send CCLD proof by POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Kristin Heffernan
NAME OF LICENSING PROGRAM MANAGER:
Quoc Huynh
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/14/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/14/2025


LIC809 (FAS) - (06/04)
Page: 5 of 14
Document Has Been Signed on 08/14/2025 02:19 PM - It Cannot Be Edited


Created By: Quoc Huynh On 08/14/2025 at 01:21 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: JUST LIKE HOME
FACILITY NUMBER: 197603936

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/14/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(a)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview and record review, the licensee did not comply with the section cited above in 1 out of 5 staff did not have a file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/21/2025
Plan of Correction
1
2
3
4
The Licensee will bring the staff's file from their other facility and send CCLD proof by POC due date.
Type B
Section Cited
CCR
87412(d)
Personnel Records
(d) The licensee shall maintain documentation that an administrator has met the certification requirements specified in Section 87406, Administrator Certification Requirements or the recertification requirements in Section 87407, Administrator Recertification Requirements.

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 in 1 out of 3 Administrators did not have an Administrative Certificate which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/21/2025
Plan of Correction
1
2
3
4
The Licensee will enroll the Administrator in the Administrative courses to begin obtaining their Administrative Certificate and send CCLD proof by POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Kristin Heffernan
NAME OF LICENSING PROGRAM MANAGER:
Quoc Huynh
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/14/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/14/2025


LIC809 (FAS) - (06/04)
Page: 9 of 14
Document Has Been Signed on 08/14/2025 02:19 PM - It Cannot Be Edited


Created By: Quoc Huynh On 08/14/2025 at 01:21 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: JUST LIKE HOME
FACILITY NUMBER: 197603936

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/14/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(h)(4)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (4) All centrally stored medications shall be labeled and maintained in compliance with state and federal laws. No persons other than the dispensing pharmacist shall alter a prescription label.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview, and record review, the licensee did not comply with the section cited above in residents' centrally stored medication and destruction records were not maintained which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/21/2025
Plan of Correction
1
2
3
4
The Licensee will update and maintain all residents centrally stored medication and destruction records and send CCLD proof by POC due date.
Type B
Section Cited
CCR
87465(e)
Incidental Medical and Dental Care Services
(e) For every prescription and nonprescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician on a prescription blank, maintained in the resident's file, and a label on the medication. Both the physician's order and the label shall contain at least all of the following information.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on interview and record review, the licensee did not comply with the section cited above in 1 resident did not have a PRN Authorization Letter which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/21/2025
Plan of Correction
1
2
3
4
The Licensee will obtain the resident's PRN Authorization Letter and send proof to CCLD by POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Kristin Heffernan
NAME OF LICENSING PROGRAM MANAGER:
Quoc Huynh
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/14/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/14/2025


LIC809 (FAS) - (06/04)
Page: 10 of 14
Document Has Been Signed on 08/14/2025 02:19 PM - It Cannot Be Edited


Created By: Quoc Huynh On 08/14/2025 at 01:21 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: JUST LIKE HOME
FACILITY NUMBER: 197603936

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/14/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(a)
Other Provisions
(a)In addition to any other requirement of this chapter, a residential care facility for the elderly shall have an emergency and disaster plan that shall include, but not be limited to, all of the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on iinterview and record review, the licensee did not comply with the section cited above in the facility was unable to locate the emergencry disaster plan which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/21/2025
Plan of Correction
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The Licensee will complete the emergency disaster plan and send CCLD proof by 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.
Kristin Heffernan
NAME OF LICENSING PROGRAM MANAGER:
Quoc Huynh
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/14/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/14/2025


LIC809 (FAS) - (06/04)
Page: 11 of 14
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: JUST LIKE HOME
FACILITY NUMBER: 197603936
VISIT DATE: 08/14/2025
NARRATIVE
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The facility had one (1) drawer with the front panel broken, leaving nails exposed. The facility had a supply of perishable and non-perishable food. Food in the refrigerator and freezer were observed to be properly stored with labels and dates. LPA observed S1 stored their refrigerated medication that was accessible to residents. Staff personal belongings were stored in a locked cabinet. Two (2) medication bottles were observed in two (2) drawers that belonged to S1. S1 secured their medications. One fire extinguisher was observed and was purchased on 05/16/2025.

BEDROOMS/RESTROOMS: There were six (6) total bedrooms, each designated as private resident bedrooms. Bedrooms #2, #3, #4, #5, and #6 had direct exits to the outside. Bedrooms were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. Extra linens were stored in cabinets located in the hallway. There were seven (7) total restrooms in the facility: four (4) attached private resident restrooms, one (1) shared resident restroom located in the hallway, one (1) restroom designated for staff and visitors located in the entryway, and one (1) restroom located in the office. Restrooms were clean, sanitary, and in operating condition with grab bars and non-slip surfaces. All restrooms were sufficiently stocked with soap, paper products, and displayed hand washing signs. LPA observed two (2) bleach bottles under the staff/visitor restroom sink and S1 secured the bottles. The shared resident restroom was observed to have a ripped window screen. Hot water was tested and measured between 123.1 degrees F and 128.3 degrees F, which is not within the required range of 105 degrees F and 120 degrees F. Additionally, LPA observed the restroom in Bedroom #4 was remodeled; S1 confirmed the facility was in the process of remodeling. No notification was provided to Community Care Licensing.

OUTDOOR AREA: The surrounding grounds had one (1) shaded patio area equipped with furniture in good condition for resident and visitor use. LPA observed a properly fenced and secured in-ground pool in the rear yard. There were two (2) emergency exits located on each side of the facility that led to the front yard. One (1) of the side exits was obstructed by garbage bins, a water hose, a cordless vacuum, and a portable toilet.

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: 08/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2025
LIC809 (FAS) - (06/04)
Page: 12 of 14
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: JUST LIKE HOME
FACILITY NUMBER: 197603936
VISIT DATE: 08/14/2025
NARRATIVE
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LPA observed three (3) windows did not have a window screen and one (1) window screen was not properly secured. Additionally, the LPA observed an ethernet cable hanging from the gutters that led into a window. The hanging ethernet cable obstructed one third of the perimeter’s passageway. The front yard had a driveway with a self-latching gate. The front yard also had a water fountain that did not contain any water.

The facility had a designated office space that was locked and contained an office, storage, emergency food and water, and extra food. The extra food observed in the refrigerator and freezer were good quality.

RECORDS: Record review began at 10:20AM. Resident records were reviewed for, but not limited to care plans, physician's report, admissions agreement, and consent forms. All records were in order. Personnel records were reviewed for, but not limited to health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. LPA observed S2’s Health Screening report was falsified as it was a copy of S1’s report. S1’s Health Screening report was dated 10/03/2019. S2’s Health Screening was also dated 10/03/2019 with the Physician’s signature date to be written over stating 10/03/2020. S1 was hired on 08/20/2019 and S2 was hired on 10/05/2020. Four (4) out of five (5) staff files did not have a current first aid/cpr training with expired training ranging from 07/11/2021 to 07/24/2025. S1 contacted secondary Administrator Evelina Vartapetova who could not provide updated documentation. Staff #3 (S3) was also confirmed as an Administrator, but did not have an Administrative Certificate. Administrator Evelina Vartapetova’s file was not found.

INFECTION CONTROL/EMERGENCY DISASTER PLAN: During today's visit, LPA was unable to review the facility's infection control plan and emergency disaster plan and staff were unable to locate the documents. S1 contacted Administrator Evelina and stated it was just done, however staff were unable to provide the LPA the documents.

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: 08/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2025
LIC809 (FAS) - (06/04)
Page: 13 of 14
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: JUST LIKE HOME
FACILITY NUMBER: 197603936
VISIT DATE: 08/14/2025
NARRATIVE
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Administrator Evelina asked for time and offered to email the documents to the LPA, however the LPA explained that if there was a current emergency, staff are unable to follow proper emergency protocols because the plans were nowhere to be found. Emergency disaster drills were allegedly conducted quarterly, however the facility could not provide documentation. Smoke and carbon monoxide detectors were tested at 10:09AM and were operational.

MEDICATIONS: Medication review began at 11:34AM. Medications were centrally stored and kept inaccessible in the entryway. Medications were observed for two (2) residents. Medications were labeled and checked for expiration dates and were not properly documented on the centrally stored medications and destruction record (CSMDR). Resident #1 (R1) had nine (9) prescribed medications and eight (8) medications were not documented. R1’s CSMDR provided was dated 07/16/2025 and R1’s current medications were filled on 07/16/2025, 07/28/2025, and 08/11/2025. R1 also had one (1) PRN (as needed) medication and the facility did not have a PRN Authorization Letter. Resident #2 (R2) had four (4) prescribed medications with one (1) medication properly documented. The one medication was filled on 04/27/2025; S1 stated R2’s son refills the medications and brought the medication in with the same bottle to the facility. The remainder of the medications were filled on 08/04/2025 and 08/07/2025. R2’s CSMDR most recent update was on 07/08/2025.

Pursuant to Title 22 CA Code of Regulations and/or Health and Safety Code, the following deficiencies were cited (Refer to LIC 809-D).

LPA reviewed the report and citations with Administrator Aleksandra Vartapetova via telephone call. S1 was designated to sign the report.

Exit interview conducted. A copy of the Appeal Rights and report was reviewed and provided.
NAME OF LICENSING PROGRAM MANAGER: Kristin Heffernan
NAME OF LICENSING PROGRAM ANALYST: Quoc Huynh
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2025
LIC809 (FAS) - (06/04)
Page: 14 of 14