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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609307
Report Date: 09/12/2025
Date Signed: 09/12/2025 06:15:44 PM

Document Has Been Signed on 09/12/2025 06:15 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:WELLBE HOMEFACILITY NUMBER:
197609307
ADMINISTRATOR/
DIRECTOR:		MKRTCHIAN, VAHEFACILITY TYPE:
740
ADDRESS:12936 WELBY WAYTELEPHONE:
(818) 414-0005
CITY:NORTH HOLLYWOODSTATE: CAZIP CODE:
91606
CAPACITY: 4CENSUS: 4DATE:
09/12/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:54 AM
MET WITH:Vahe Mkrtchian, AdministratorTIME VISIT/
INSPECTION COMPLETED:
06:25 PM
NARRATIVE
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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 Simonyan, Staff. Vahe Mkrtchian was contacted by staff and he arrived at 10:15am to conduct the visit. The reason for today's visit was provided.

The facility is a single storey home consisting on a living room, a kitchen, a dining room, 5 bedrooms, 3 full bathrooms and a detached garage located at the back of the property. Part of the garage has been converted to an office and part of the garage is used for storage. The facility is fire cleared for 5 non-ambulatory and 1 bedridden. However, at the request of the Licensee, the facility is licensed for a total of 4 residents of which 1 may be bedridden. Any of the resident bedrooms may be used for the bedridden resident.

On today's visit all 12 domains of the CARE Inspection Tool was reviewed, 4 Resident and 5 staff files were reviewed. Also reviewed were the Plan of Operations, Disaster Preparedness Plan and the Infection Control Plan.

The following were observed on today's visit:
  • The living room, dining room, kitchen were all furnished with the appropriate furniture and equipment for it's designated use.

continued on LIC809-C
NAME OF LICENSING PROGRAM MANAGER: Kristin Heffernan
NAME OF LICENSING PROGRAM ANALYST: Christine Yee
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/12/2025
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: WELLBE HOME
FACILITY NUMBER: 197609307
VISIT DATE: 09/12/2025
NARRATIVE
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  • Bedrooms #1 - Bedroom #4 were all observed with 1 each of the following: a hospital bed, a chair, a night stand, a lamp, a dresser and a built in closet. All 4 bedrooms have an outside exiting door. Auditory devices were mounted on the doors and an announcement with the room number is made in the kitchen when the doors are opened. Located inside Bedroom #4 is a private bathroom equipped with a walk in shower, a shower chair, a toilet, a sink, grab bars and a slip resistant mat. Water temperature was tested and read 117.1 degrees Fahrenheit.
  • Located by the front door is the bedroom for 2 live in staff. It is furnished with 2 beds, dressers and various personal belongings.
  • Located by Bedroom #3 is the staff bathroom equipped with a walk in shower, chair, toilet, a sink, grab bars and slip resistant mat. Water temperature was tested and read 118.6 degrees Fahrenheit.
  • The common bathroom was observed with a walk in shower, a chair, a sink, a toilet, grab bars and slip resistant mats. Water temperature read 118.7 degrees Fahrenheit.
  • Medications are stored in the locked closet by the front door.
  • Sufficient perishable foods for a minimum of 2 days and non-perishable foods for 7 days were observed. however a recommendation was made for the Administrator to purchase actual breakfast foods. Eighteen, one gallon bottles of water was observed, in addition to 3 full packages of 24, 16.9 oz bottles of water.
  • Facility has current general liability insurance that meets Title 22 requirements and a Surety Bond for $11 K.
  • First Aid Kit and first aid manual was observed and met Title 22 requirements.
  • The hardwired smoke detectors located in the resident rooms, staff room, living room and hallways were tested and were operational. The only combination smoke/carbon monoxide detector is located in the resident room hallway.
  • The only fire extinguisher is located in the dining room and was purchased on 4/9/25
  • Per tour of the outside areas, the backyard has a gazebo furnished with a table and chairs for outside activities.
  • The garage is used for storage of extra wheelchairs and furniture and part of the garage is used as an office.
  • The trash cans stored behind the garage/office were observed to be tightly sealed.


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

DATE: 09/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2025
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: WELLBE HOME
FACILITY NUMBER: 197609307
VISIT DATE: 09/12/2025
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  • The front yard was observed to be clean and well maintained.
  • The Administrator will return the empty oxygen tanks store in the garage and advise LPA Yee when done.

No deficiencies were cited on today's visit.

Exit interview was conducted and copy of the report was provided.
NAME OF LICENSING PROGRAM MANAGER: Kristin Heffernan
NAME OF LICENSING PROGRAM ANALYST: Christine Yee
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/16/2025 09:12 AM - It Cannot Be Edited

Document is an Amendment of Original Document on 09/15/2025 10:29 AM


Created By: Christine Yee On 09/12/2025 at 06:10 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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: WELLBE HOME
FACILITY NUMBER: 197609307

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/12/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87463(b)
Reappraisals
(b) The reappraisal shall document significant changes in the resident's physical, mental, cognitive, behavioral, or functional condition, including those required to be documented as specified in Section 87466, Observation of the Resident.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above in 3 out of 4 resident files reviewed as the last Appraisal/Needs and Service was completed for Resident #2 on 2/28/24, Resident #3 on 2/28/24 and Resident #4 on 5/10/24 and no annual reassesment have been conducted since, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/22/2025
Plan of Correction
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The Licensee should ensure that an assessment is completed annually to document changes to the resident's physical, mental, cognitive, behavioral, or functional condition per observation of the resident. Licensee will schedule a meeting with each resident and their responsible party to update Resident #2, Resident #3 and Resident #4's care plan to ensure that their needs are being met. Evidence of completion will be faxed to the Department by 9/22/25.
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:
Christine Yee
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/12/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/12/2025


LIC809 (FAS) - (06/04)
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