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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608550
Report Date: 04/03/2025
Date Signed: 04/04/2025 08:01:57 AM

Document Has Been Signed on 04/04/2025 08:01 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:QUEEN COMFORT CARE CENTER, INC.FACILITY NUMBER:
197608550
ADMINISTRATOR/
DIRECTOR:		GOHAR AMBARTSUMYANFACILITY TYPE:
740
ADDRESS:6534 MCLENNAN AVENUETELEPHONE:
(818) 469-2995
CITY:VAN NUYSSTATE: CAZIP CODE:
91406
CAPACITY: 6CENSUS: 6DATE:
04/03/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:45 AM
MET WITH:Nino GhelashviliTIME VISIT/
INSPECTION COMPLETED:
04:45 PM
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Licensing Program Analyst (LPA) Sandra Urena arrived at the facility to conduct an unannounced required annual visit. LPA was greeted by staff who called the Licensee and the Administrator. The Licensee, Nino Gelashvili and Administrator Gohar Ambartsumyan arrived shortly thereafter. LPA Urena explained the reason for the visit. The LPA and the Licensee 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.

KITCHEN: Knives are stored in a locked drawer next to the stove. Kitchen appliances were in operable condition. The refrigerator and freezer need a thermometer to monitor the temperatures. The facility has a sufficient supply of perishable and non-perishable food. Cleaning supplies were observed on top and under the kitchen sink unlocked and accessible to residents in care. Staff locked the cabinet door at the time of the visit. Hot water in the kitchen sink faucet measured at 115.8 degrees Fahrenheit (F). The LPA observed medications (insulin injections) located in the door area of the refrigerator and the freezer, and not locked in a secured box. The medications were accessible to residents in care and pose an immediate danger to residents in care. COMMON AREAS: At the time of the visit, living room and dining room furniture was observed to be in good condition. Cameras were observed at the time of the visit; however, Licensee stated that they are not working at the moment. Smoke detector and carbon monoxide were tested at 12:10 p.m. and operational at the time of the visit. The fire extinguisher was fully charged and last purchased on 04/14/2024. Exits have functioning auditory devices, however, at the time of the visit they were not activated. The licensee activated them at the time of the visit. The LPA observed required postings throughout the common space, however the CCL poster, “If you see something, say something” poster was missing at the time of the visit. Licensee stated that one of the residents probably took it down. The Licensee post it in a location where it won’t be removed by residents in care.

NAME OF LICENSING PROGRAM MANAGER: Kasandra Lopez
NAME OF LICENSING PROGRAM ANALYST: Sandra Urena
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/03/2025
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: QUEEN COMFORT CARE CENTER, INC.
FACILITY NUMBER: 197608550
VISIT DATE: 04/03/2025
NARRATIVE
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 The laundry room is located next to the kitchen area. The side door leading to the hallway was observed to be unlocked at the time of the visit. Bedrooms: Had appropriate furnishings, and sufficient lighting. The LPA observed shared bedroom #4 to have a fireplace which had a cover and a painting in front of it. The LPA observed boxes of items stored in the corner of the room. The Licensee stated that staff are cleaning the garage, and they stored the boxes temporarily in the room. The LPA explained to the Licensee that the bedroom cannot be used for storage, even temporarily. The Licensee stated that they will remove the boxes as soon as possible. There was a linen closet in the hallway with extra towels and linens.RESTROOMS: The two (2) resident restrooms appeared clean and sanitary. The toilet in the hallway bathroom was not in operating condition at the time of the visit. The Licensee stated that the private bathroom in bedroom #4 had paper disposed in it, making the toilet in the hallway to get backed up, consequently the staff had to shut off the water in the toilet to prevent it from backing up. The toilet seat was observed to be loose, causing a potential hazard for the residents in care. The Licensee asked a handy person to fix the toilet while the LPA was conducting the annual inspection. At the time of the inspection the LPA did not observe a non-skid mat available in the tub. The Licensee stated that staff remove the mat when the residents are not being showered or given a bath.

The private bathroom’s shower was observed to have a shower chair in disrepair, and in not useable condition. The Licensee stated that residents/staff do not use the shower seat, but that they had kept the seat to use as a sample to order a new shower chair, which they had already ordered. The LPA advised the Licensee to throw away the shower seat. The shower chair poses a potential hazard to residents in care.

The bathrooms were sufficiently stocked with supplies and paper towels; towels and washcloths are not shared. The hot water temperature was measured at 116.2 degrees Fahrenheit.

OUTDOORS: The backyard has an outdoor area for residents’ use, however at the time of the visit the LPA observed the shaded area to be in disrepair due to the shade fabric (patio umbrella and canopy) being torn. The Licensee stated that the fabric was torn in the last few months. The LPA advised the Licensee to replace the shade items. The outdoor furniture was observed to be piled up together, preventing use of it. The licensee will work on the seating/shaded area to make it available for residents’ use. The facility has a side gate that self-latches with no obstructions in case of an emergency at this time. There were no bodies of water noted. LPA observed a sufficient amount of space for activities. There was a detached garage located on site. LPA observed garage to store extra furniture and medical supplies at this time. Emergency water was stored in the garage.

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

DATE: 04/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/03/2025
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: QUEEN COMFORT CARE CENTER, INC.
FACILITY NUMBER: 197608550
VISIT DATE: 04/03/2025
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RECORDS: Records review began at 1:05 p.m., Residents’ records were reviewed for, but not limited to care plans, medical records, admissions agreement, 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 annual training. All files were in order.

MEDICATIONS: Medications are centrally stored and locked in a cabinet in the laundry room area, however at the time of the visit the LPA observed the medicine cabinet to be unlocked and accessible to residents in care. The Licensee stated that the key had broken inside the lock and the staff informed of the incident today in the morning. The Licensee stated that the lock will be replaced. Furthermore, the LPA observed a bottle of medication (Risperidone), the bottle contained two pills inside, located inside the laundry cabinet which was also unlocked. The LPA observed medications (insulin injections) located in the door area of the refrigerator and the freezer, and not locked in a secured box. The medications were accessible to residents in care and pose an immediate danger to residents in care.

Medications review began at 2:29 p.m.; medications are labeled and checked for expiration dates. Medications are properly documented on the centrally stored medications and destruction record. However, the LPA observed errors during the medication audit. The medication Trazodone (50mg./30 pills) was observed to have an inaccurate amount of pills, when compared to the Centrally Store and Destruction Record (LIC 622) information.

The LPA reviewed the following documents:


- LIC500 Personnel Report
- LIC9020 Client Roster-Licensee will add the name of the Clinic/physician for each resident in the list.
- Certificate of Liability of Insurance (expired 04/01/2025), Licensee will email LPA a picture of a valid
certificate.
_ Emergency Drill Logs

The following deficiencies were observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties.

Citations were issued at this time. Exit interview. A copy of the report was issued, and Appeal Rights were issued.

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

DATE: 04/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/03/2025
LIC809 (FAS) - (06/04)
Page: 4 of 7
Document Has Been Signed on 04/04/2025 08:01 AM - It Cannot Be Edited


Created By: Sandra Urena On 04/03/2025 at 03:50 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: QUEEN COMFORT CARE CENTER, INC.
FACILITY NUMBER: 197608550

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/03/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(c)
Storage Space and Access
(c) Except as specified in subsection (d), the licensee shall implement reasonable interventions in order to ensure that nutritional supplements, vitamins, alcohol, cigarettes and other potentially toxic substances, such as certain plants, gardening supplies, and auto supplies, are stored so as not to pose a hazard to residents.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) , the licensee did not comply with the section cited above in a cleaning supplies where in the bottom cabinet which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/03/2025
Plan of Correction
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LIcensee ensured that all cabinets were locked.
Type A
Section Cited
CCR
87465(h)(2)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation)], the licensee did not comply with the section cited above as the medication cabinet door lock was observed to be broken, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/03/2025
Plan of Correction
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Licensee corrected the deficiency on today's visit by having the door locked fixed and working propertly.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Kasandra Lopez
NAME OF LICENSING PROGRAM MANAGER:
Sandra Urena
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/03/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/03/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/04/2025 08:01 AM - It Cannot Be Edited


Created By: Sandra Urena On 04/03/2025 at 03:50 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: QUEEN COMFORT CARE CENTER, INC.
FACILITY NUMBER: 197608550

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/03/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(c)(2)
Incidental Medical and Dental Care Services
(c) 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
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Based on [(observation) and (record review)], the licensee did not comply with the section cited above as one out of two bottles, medication Trazodone (50mg./30 pills) was observed to have an inaccurate amount of pills, when compared to the Centrally Store and Destruction Record (LIC 622) information. which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/11/2025
Plan of Correction
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The Licensee will provide training to caregivers on how to properly follow physician's directions.
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.
Kasandra Lopez
NAME OF LICENSING PROGRAM MANAGER:
Sandra Urena
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/03/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/03/2025


LIC809 (FAS) - (06/04)
Page: 6 of 7
Document Has Been Signed on 04/04/2025 08:01 AM - It Cannot Be Edited


Created By: Sandra Urena On 04/03/2025 at 03:50 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: QUEEN COMFORT CARE CENTER, INC.
FACILITY NUMBER: 197608550

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/03/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(e)(6)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (6) Toilet, handwashing and bathing facilities shall be maintained in operating condition. Additional equipment shall be provided in facilities accommodating physically handicapped and/or nonambulatory residents, based on the residents' needs.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation the licensee did not comply with the section cited above in one out of one toilet which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/03/2025
Plan of Correction
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Toilet was fixed at the time of the visit.
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.
Kasandra Lopez
NAME OF LICENSING PROGRAM MANAGER:
Sandra Urena
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/03/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/03/2025


LIC809 (FAS) - (06/04)
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