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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609298
Report Date: 09/10/2025
Date Signed: 09/10/2025 06:57:33 PM

Document Has Been Signed on 09/10/2025 06:57 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:MOM AND DADS RETREAT INCFACILITY NUMBER:
197609298
ADMINISTRATOR/
DIRECTOR:		ARMENUI AMY ARZUMANYANFACILITY TYPE:
740
ADDRESS:15214 WYANDOTTE STREETTELEPHONE:
(818) 390-7012
CITY:VAN NUYSSTATE: CAZIP CODE:
91405
CAPACITY: 6CENSUS: 6DATE:
09/10/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:56 AM
MET WITH:Armenui Arzumanyan, AdministratorTIME VISIT/
INSPECTION COMPLETED:
07:05 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 using the complete CARE Inspection Tool and was let into the home by Karine Khojikyan, Staff. Armenui Arzumanyan, Administrator was contacted by staff and she arrived at 10:20am to conduct the visit. The reason for today's visit was explained.

The facility is a single storey home located in the back of the property consisting of 2 separate buildings with separate addresses. The home consists of a living room, dining room, kitchen, a den, 5 bedrooms and 4 full bathrooms. No bodies of water were observed on the premises. The facility is fire cleared for 5 NON- AMBULATORY and 1 BEDRIDDEN resident. Bedroom #3 is designated for bedridden use.

On today's visit, LPA Yee reviewed the entire CARE Inspection Tool, 6 Resident and 6 Staff files, Plan of Operations, Disaster Preparedness and Infection Control Plan.

The following was observed on today's visit:
  • the living room was observed furnished with a sofa, love seat, a desk, a built in bar, chairs and filing cabinets for staff and resident files behind the bar.
  • The family room was observed with plenty of sitting, a dining table and 6 chairs, a fire place that was secured with a glass door and a fire screen.

continued on LIC809-C
NAME OF LICENSING PROGRAM MANAGER: Kristin Heffernan
NAME OF LICENSING PROGRAM ANALYST: Christine Yee
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/10/2025
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 4
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 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: MOM AND DADS RETREAT INC
FACILITY NUMBER: 197609298
VISIT DATE: 09/10/2025
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 kitchen is equipped with the usual stove, dishwasher, oven and refrigerator. Food supply was reviewed in the pantry, refrigerator and the outside refrigerator, there was sufficient perishable foods for a minimum of 2 days and non-perishable foods for a minimum of 7 days were observed. A recommendation was made to supplement the canned proteins with additional cans of chicken and fish. Located inside the panty is the only fire extinguisher purchased on 6/30/25.
  • Bedrooms #1, #2, #4 and #5 were each furnished with a hospital bed, a night stand, a lamp, a chair, a dresser and a built in closet except for bedroom #5. Bedroom #5 has a portable closet.
  • Bedroom #3 was observed with 2 hospital beds, 2 night stands, 2 chairs, 2 lamps and a walk in closet.
  • a shared dresser. The auditory device on the door was tested and was operational.
  • Located inside bedroom #2, #3 and #4, all have a private bathroom. The bathrooms located inside
  • bedroom #2 and #4 contained a walk in shower, a shower chair, grab bars, a slip resistant mat, a toilet with a riser. Water temperature was tested and read 115.4 in bedroom #2 and 118.6 in bedroom #4. Bedroom #3 was observed with a walk in shower, a toilet with a riser, a bidet, grab bars, a slip resistant mat, 2 sink vanity and a jacuzzi bath tub. Water temperature read 115.5 degrees Fahrenheit.
  • the common bathroom was observed with a walk in shower, chair, grab bars, a slip resistant mat, a single sink vanity, a toilet. Water temperature was tested and read 118.1 degree Fahrenheit.
  • the first aid kit and manual met Title 22 requirements.
  • the hardwired smoke detectors located inside the 5 resident rooms, hallway, living room an family room were tested and were operational. Per test, the combination smoke/carbon monoxide detectors are located in the hallway and living room. The fire rated doors for bedroom #1 and the hallway were operational.
  • the auditory devices on the outside exiting doors in the living room, family room, bedroom #1 and bedroom #3 were operational.
  • the facility has current general liability insurance that meets Title 22 requirements.
  • centrally stored medications a re stored in locked cabinets in the kitchen
  • Cleaning solutions, disinfectants and toxins are stored in a locked cabinet in the laundry area and in a locked cabinet under the kitchen sink.
  • knives are stored in a locked case inside a kitchen drawer.


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

DATE: 09/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2025
LIC809 (FAS) - (06/04)
Page: 3 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: MOM AND DADS RETREAT INC
FACILITY NUMBER: 197609298
VISIT DATE: 09/10/2025
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
  • Per tour of the outside areas, a covered patio furnished with wicker chairs, storage cabinets and a refrigerator was observed. The outside areas were observed to be clean. The trash cans are stored in the front by the gate. Per Administrator, new trash cans were ordered and are pending delivery.




No deficiencies were cited on today's visit.
NAME OF LICENSING PROGRAM MANAGER: Kristin Heffernan
NAME OF LICENSING PROGRAM ANALYST: Christine Yee
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2025
LIC809 (FAS) - (06/04)
Page: 4 of 4