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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608459
Report Date: 08/27/2025
Date Signed: 08/28/2025 11:29:22 AM

Document Has Been Signed on 08/28/2025 11:29 AM - 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:EMVY BOARD AND CARE FACILITYFACILITY NUMBER:
197608459
ADMINISTRATOR/
DIRECTOR:		EMMA KOCHINYANFACILITY TYPE:
740
ADDRESS:14164 COHASSET STREETTELEPHONE:
(818) 947-1711
CITY:VAN NUYSSTATE: CAZIP CODE:
91405
CAPACITY: 6CENSUS: 4DATE:
08/27/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:42 AM
MET WITH:Emma Kochinyan, AdministratorTIME VISIT/
INSPECTION COMPLETED:
09:15 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) Christine Yee conducted an unannounced required Annual Inspection and used the complete CARE Inspection Tool. LPA met with Emma Kochinyan, Administrator. The reason for today's visit was provided.

The home is a single family home consisting of a living room, a dining room, a kitchen, a family room, 3 resident bedrooms, 2 bathrooms and a attached garage. The facility is fire cleared for 5 NON-AMBULATORY residents and 1 BEDRIDDEN resident. Based on the review of the rooms, Bedroom #3, located at the back right corner of the home, has an outside exiting door with a ramp and would be the room designated for bedridden use.

All 12 domains of the Care Inspection Tool was reviewed, 4 resident and 4 staff files were reviewed on today's visit.

The following were observed:
  • The kitchen was appropriated equipped with a refrigerator, oven, microwave, coffee maker. The water temperature was tested and read 109.6 degrees Fahrenheit.
  • Sufficient perishable food for a minimum 2 day and non-perishable foods for 7 days were observed.
  • The dining room was observed with a table and 4 chairs. 2 dining room chairs were stored in the garage. One of the 2 chairs were broken. Located in the dining room is the only fire extinguisher. It was last serviced on 3/31/25.

continued on LIC809-C
NAME OF LICENSING PROGRAM MANAGER: Kristin Heffernan
NAME OF LICENSING PROGRAM ANALYST: Christine Yee
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 08/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/28/2025
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 15
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 15
Document Has Been Signed on 08/28/2025 11:29 AM - It Cannot Be Edited


Created By: Christine Yee On 08/27/2025 at 07:21 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: EMVY BOARD AND CARE FACILITY
FACILITY NUMBER: 197608459

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/27/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.618(b)
Other Provisions
(b) At least one administrator, facility manager, or designated substitute who is at least 21 years of age and has qualifications adequate to be responsible and accountable for the management and administration of the facility pursuant to Title 22 of the California Code of Regulations shall be on the premises 24 hours per day. The designated substitute may be a direct care staff member who shall not be required to meet the educational, certification, or training requirements of an administrator. The designated substitute shall meet qualifications that include, but are not limited to, all of the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in all 2 counts as no LIC308s were completed were not observed in staffs' files for the morning and night shift which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/04/2025
Plan of Correction
1
2
3
4
The Licensee will ensure that an LIC308 designating a responsible staff for each shift is completed and maintained in the staff file for when the Administrator is not present at the facility by 9/4/25
Type B
Section Cited
CCR
87470(b)(2)(C)
Infection Control Requirements
(b) In addition to subsection (a), when one or more residents in the facility are diagnosed with a contagious disease, the following shall apply: (2) All staff and volunteers providing direct care to a resident who has a contagious disease shall wear appropriate Personal Protective Equipment (PPE) to prevent exposure to infectious agents or chemicals through the respiratory system, skin, or mucous membranes of the eyes, nose, or mouth. PPE may include gloves, gowns, masks, respirators, shoe coverings and eye protection. (C) The licensee shall ensure all staff and volunteers are trained in the proper use of all required PPE prior to being around residents and annually thereafter.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review and interview with the Administrator, the licensee did not comply with the section cited above in all 4 counts. Staff have not been provided with PPE training which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/04/2025
Plan of Correction
1
2
3
4
The Licensee will ensure that all staff are provided with PPE training when hired and annually thereafter. Licensee will provide evidence that the staff have been provided with PPE training by 9/4/25
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:
Christine Yee
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/27/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/28/2025


LIC809 (FAS) - (06/04)
Page: 3 of 15
Document Has Been Signed on 08/28/2025 11:29 AM - It Cannot Be Edited


Created By: Christine Yee On 08/27/2025 at 07:21 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: EMVY BOARD AND CARE FACILITY
FACILITY NUMBER: 197608459

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/27/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87208(c)
Plan of Operation
(c) A licensee who accepts or retains bedridden persons shall include additional information in the plan of operation as specified in Section 87606, Care of Bedridden Residents.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above as per review of the Plan of Operations, there was no bedridden plan observed which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/04/2025
Plan of Correction
1
2
3
4
The Licensee will review their Plan of Operations and update the Plan of Operations to address how the care of Bedridden residents wiill be addressed by 9/4/25
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 record review, the licensee did not comply with the section cited above in all counts as copies of CEUs and a current Administrator Certificate was requested and the Administrator could not provide evidence that they were recertified as an Administrator] which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/04/2025
Plan of Correction
1
2
3
4
The Licensee will contact the Administrator Certification Unit and obtain evidence that she is still a certified Administrator. The Licensee will provide a copy of the Administrator to LPA for review by 9/4/25
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:
Christine Yee
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/27/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/28/2025


LIC809 (FAS) - (06/04)
Page: 4 of 15
Document Has Been Signed on 08/28/2025 11:29 AM - It Cannot Be Edited


Created By: Christine Yee On 08/27/2025 at 07:21 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: EMVY BOARD AND CARE FACILITY
FACILITY NUMBER: 197608459

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/27/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(d)
Incidental Medical and Dental Care Services
(d) If the resident is unable to determine his/her own need for a prescription or nonprescription PRN medication, and is unable to communicate his/her symptoms clearly, facility staff designated by the licensee, shall be permitted to assist the resident with self-administration, provided all of the following requirements are met:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above as it was observed that Resident #4 has PRN Ambien and Acetaminophen and does not have a completed PRN Authorization by the physician on file. which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/04/2025
Plan of Correction
1
2
3
4
The Licensee will contact the prescribing physician to obtain a complete PRN Authorization Letter for the PRN medications and maintain in Resident #4 file by 9/4/25
Type B
Section Cited
CCR
87465(d)(3)
Incidental Medical and Dental Care Services
(d) If the resident is unable to determine his/her own need for a prescription or nonprescription PRN medication, and is unable to communicate his/her symptoms clearly, facility staff designated by the licensee, shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (3) The date and time the PRN medication was taken, the dosage taken, and the resident's response shall be documented and maintained in the resident's facility record.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above as it was observed that Resident #4 who has PRN Ambien was given a daily dose from 7/16/25 and there is no documentation of the date it was dispensed, no doctor instructions, time it was dispensed and no results of the dose cocumented by the staff which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/04/2025
Plan of Correction
1
2
3
4
The Licensee will provide a written plan of action as to how she will ensure that all PRN medications are documented when it is dispensed and submit to the Department by 9/4/25
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:
Christine Yee
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/27/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/28/2025


LIC809 (FAS) - (06/04)
Page: 5 of 15
Document Has Been Signed on 08/28/2025 11:29 AM - It Cannot Be Edited


Created By: Christine Yee On 08/27/2025 at 07:21 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: EMVY BOARD AND CARE FACILITY
FACILITY NUMBER: 197608459

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/27/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(a)(1)
(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: (1) Evacuation procedures, including identification of an assembly point or points that shall be included in the facility sketch.

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 as the facility sketch does not identify the meeting point which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/04/2025
Plan of Correction
1
2
3
4
The Licensee will update the facility sketch and note the assembly point on all facility sketches. A copy of the updated facility sketch will be provided to Licensing by 9/4/25
Type B
Section Cited
CCR
87632(d)(2)
Hospice Waiver
(d) If the Department grants a hospice care waiver it shall stipulate terms and conditions of the waiver as necessary to ensure the well-being of terminally ill residents and of all other facility residents, which shall include, but not be limited to, the following requirements: (2) The licensee shall notify the Department in writing within five working days of the initiation of hospice care services for any terminally ill resident in the facility or within five working days of admitting a resident already receiving hospice care services. The notice shall include the resident's name and date of admission to the facility and the name and address of the hospice. This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above as it was observed that Resident #4 has been receiving hospice services since 4/22/25 and it has not been reported to the Department which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/04/2025
Plan of Correction
1
2
3
4
The Licensee will submit a notice of Hospice Initiation for Resident #4 to the Department by 9/4/25
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:
Christine Yee
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/27/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/28/2025


LIC809 (FAS) - (06/04)
Page: 6 of 15
Document Has Been Signed on 08/28/2025 11:29 AM - It Cannot Be Edited


Created By: Christine Yee On 08/27/2025 at 07:21 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: EMVY BOARD AND CARE FACILITY
FACILITY NUMBER: 197608459

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/27/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87618(b)(3)(A)
Oxygen Administration - Gas and Liquid
(3) Ensuring that the use of oxygen equipment meets the following requirements: (A) A report shall be made in writing to the local fire jurisdiction that oxygen is in use at the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on interview and observation, the licensee did not comply with the section cited above as Resident #2 was observed with a oxygen concentrator for as needed use and 2 full tanks of oxygen was observed stored in the garage for a former resident which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/29/2025
Plan of Correction
1
2
3
4
The Licensee will immediately notify the local fire department in writing of the use of the oxygen concentrator and the presence of oxygen tanks locate in the garage by 8/29/25.
Type B
Section Cited
CCR
87618(b)(3)(B)
Oxygen Administration - Gas and Liquid
(3) Ensuring that the use of oxygen equipment meets the following requirements: (B) “No Smoking-Oxygen in Use” signs shall be posted in the appropriate areas.

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 as there were not signs observed posted on the doors that there is oxygen in use at the facility which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/29/2025
Plan of Correction
1
2
3
4
The Licensee will ensure that "No Smoking -Oxygen in Use" signs are posted so everyone is aware that there is oxygen in use at the facility.
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:
Christine Yee
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/27/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/28/2025


LIC809 (FAS) - (06/04)
Page: 7 of 15
Document Has Been Signed on 08/28/2025 11:29 AM - It Cannot Be Edited


Created By: Christine Yee On 08/27/2025 at 07:21 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: EMVY BOARD AND CARE FACILITY
FACILITY NUMBER: 197608459

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/27/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87633(b)(6)
Hospice Care for Terminally Ill Residents
(b) A current and complete hospice care plan shall be maintained in the facility for each hospice resident and include the following: (6) Identification of the training needed, which staff members need this training, and who will provide the training relating to the licensee's responsibilities for implementation of the hospice care plan.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review], the licensee did not comply with the section cited above as it was observed that there is no hospice care plan or the specific services that will be provided in Resident #4's Hospice file in which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/04/2025
Plan of Correction
1
2
3
4
The Licensee will contact the hospice agency for Resident #4 and obtain the complete care plan, the required training needed for the care of Resident #4 and the specifc services to be provided to Resident #4 by 9/4/25. Provide evidence that the care plan, required training and services to be provided has been obtained.
Type B
Section Cited
CCR
87307(3)(b)
87307 Personal Accommodations and Services
(3) Equipment and supplies necessary for personal care and maintenance of adequate hygiene practice shall be readily available to each resident. The resident may provide the following items; however, if the resident is unable or chooses not to provide them, the licensee shall assure provision of:
(B) Bedroom furniture, which shall include, for each resident, a chair, night stand, a lamp, or lights sufficient for reading, and a chest of drawers. This requirement was not met as evidenced by:

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 per tour of the facility, it was observed that bedroom #2 and bedroom #3 do not have chairs and bedroom #2 does not have any dressers, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/04/2025
Plan of Correction
1
2
3
4
Licensee will ensure that all the required Title 22 furniture is provided to all residents. Licensee will purchase 2 chairs each for bedroom #2 and bedroom #3 and dressers for bedroom #2. The dressers must be 8 cubic feet for each resident. Proivide evidence to the Department by 9/4/25.
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:
Christine Yee
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/27/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/28/2025


LIC809 (FAS) - (06/04)
Page: 8 of 15
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: EMVY BOARD AND CARE FACILITY
FACILITY NUMBER: 197608459
VISIT DATE: 08/27/2025
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
Page 2
  • The living room was furnished with a sofa and love seat.
  • The family room was observed with a sofa and a coffee table.
  • The family room was observed with a sofa and a coffee table.
  • Bedroom #1 is currently rented as a private bedroom and was observed with a hospital bed, a night stand, a chair, a lamp ***dresser and a built in closet
  • Bedroom #2 and Bedroom #3 were both observed with 2 hospital beds, 2 night stands, 2 lamps and a built in closet. No chairs were observed in both rooms. Bedroom #2 does not have any dressers. Bedroom #3 has curtains but one panel is sheer and the licensee will replace with a solid panel for privacy.
  • Extra linens were observed in the linen closet in the hallway.
  • The private bathroom located inside Bedroom #3 is equipped with a walk in shower, grab bars, a slip resistant mat, a toilet and a single sink vanity. Water temperature was tested and read 109 degrees Fahrenheit.
  • The common bathroom located by Bedroom #1 is equipped with a walk in shower, a shower chair, grab bars, slip resistant mat, a toilet, a single sink vanity. Water temperature was tested and read 108.4 degrees Fahrenheit.
  • The hardwired smoke detectors located inside the residents' rooms, hallway, and in the living room were tested and were operational. The only smoke/carbon monoxide combination detector is located in the resident hallway.
  • The facility has current general liability insurance that meets Title 22 requirements.
  • Per file review, all staff have current first aid training. The Administrator was unable to provide evidence of CEUs for courses taken for Administrator recertification or a copy of current Administrator Certificate.
  • Per file review, the Physician's report for Resident #2 indicates that the resident is bedridden due physical and mental capacity. However, per observation of Resident #2 , the resident is able to turn, able to straighten up the upper body when slumped over during sleep and is able to seat up when transferred to a chair. The facility is fire cleared for one bedridden and the designated room for bedridden use is Bedroom #3. Resident #2 was placed in Bedroom #1, which is fire cleared for


continued on LIC809-C
NAME OF LICENSING PROGRAM MANAGER: Kristin Heffernan
NAME OF LICENSING PROGRAM ANALYST: Christine Yee
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2025
LIC809 (FAS) - (06/04)
Page: 12 of 15
Document Has Been Signed on 08/28/2025 11:29 AM - It Cannot Be Edited


Created By: Christine Yee On 08/28/2025 at 01:50 AM
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: EMVY BOARD AND CARE FACILITY
FACILITY NUMBER: 197608459

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/27/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
87303 Maintenance and Operation
(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provisions of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement was not met as evidenced by:

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 as it was observed that the dining room table had only 4 dining chairs for use and 2 dining room chairs were stored in the garage. One of the dining room chairs stored in the garage was broken which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/04/2025
Plan of Correction
1
2
3
4
Licensee will ensure that the appropriate furniture is provided in the quantity for the licensed capacity for residents use at all times. Licensee will repair or replace the broken chair and make it available for residents' use by 9/4/25.
Type B
Section Cited
CCR
87465(b)
87465 Incidental Medical and Dental Care
(b) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (2) Once ordered by the physician the medication is given according to the physician's directions.


This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review and interview with the Administrator, the licensee did not comply with the section cited above per review of Resident #4 medications, it was noted that Resident #4 was prescribed Ambien as needed on 7/16/25 but it was being dispensed daily as a routine medication without a change order which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/04/2025
Plan of Correction
1
2
3
4
Licensee will contact the prescribing physician and get clarification on the correct dose and frequency that the PRN Ambien is to be dispensed on a script and submit a copy to the Department by 9/4/25.
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:
Christine Yee
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/27/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/28/2025


LIC809 (FAS) - (06/04)
Page: 13 of 15
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: EMVY BOARD AND CARE FACILITY
FACILITY NUMBER: 197608459
VISIT DATE: 08/27/2025
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
Page 3
  • non-ambulatory. No citations were issued during the visit pending clarification needed from Resident #2's physician regarding the residents ambulatory status. The Licensee will obtain an updated medical assessment from the doctor of Resident #2 and submit the final determination to the Department. Once clarification is obtained, any deficiencies as a result of Resident #2's placement in bedroom #1 will be addressed on a return visit.
  • Per tour of the attached garage, it is primarily used for storage of extra furniture, wheel chairs, drinking water, cleaning solutions and houses the washer and dryer.
  • Per tour of the facility, inside and outside, a covered patio with seating was observed in the backyard. A metal ramp from Bedroom #3 and another ramp from the dining room was observed. Also located on the patio was a second refrigerator that contained more perishable foods. An apple and pomegranate tree was observed in the backyard. The trash cans were observed on the curb for trash pick up. The outside areas were clean.



Deficiencies were cited under California Code of Regulation, Title 22, Division 6, Chapter 8


Exit interview was conducted, APPEALS RIGHTS were discussed and a copy was given.
NAME OF LICENSING PROGRAM MANAGER: Kristin Heffernan
NAME OF LICENSING PROGRAM ANALYST: Christine Yee
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2025
LIC809 (FAS) - (06/04)
Page: 14 of 15
Document Has Been Signed on 08/28/2025 11:29 AM - It Cannot Be Edited


Created By: Christine Yee On 08/28/2025 at 10:35 AM
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: EMVY BOARD AND CARE FACILITY
FACILITY NUMBER: 197608459

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/27/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87463(a)
87463 Reappraisals
a) The pre-admission appraisal, as specified in Section 87457, Pre-Admission Appraisal, shall be updated in writing as frequently as necessary or once every 12 months, whichever occurs first, to note significant changes in condition, as defined in Section 87101, Definitions, and to keep the appraisal accurate. For the purposes of this section, the updated pre-admission appraisal shall be referred to as the reappraisal.

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 3 out of 4 counts as Resident #1(last appraiisal 2/20/24), Resident #2 (last appraisal 9/10/23)and Resident #3 (last appraisal 5/24/24 have not beein reappraised since the last noted date, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/04/2025
Plan of Correction
1
2
3
4
The Licensee will schedule an appointment with Resident #1, Resident #2 and Resident #3 families and the residents' themselves to conduct a reappraisal and update their care plan based on any changes in condition or any identified need by 9/4/25. Licensee will provide evidence that the reappraisal has been completed by 9/4/25.
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:
Christine Yee
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/27/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/28/2025


LIC809 (FAS) - (06/04)
Page: 15 of 15