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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609317
Report Date: 04/04/2025
Date Signed: 04/04/2025 11:41:28 AM

Document Has Been Signed on 04/04/2025 11:41 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:BLUE HORIZONFACILITY NUMBER:
197609317
ADMINISTRATOR/
DIRECTOR:		DAVTIAN, ZHANNAFACILITY TYPE:
740
ADDRESS:11727 BLYTHE STREETTELEPHONE:
(818) 640-4703
CITY:NORTH HOLLYWOODSTATE: CAZIP CODE:
91605
CAPACITY: 6CENSUS: DATE:
04/04/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:25 AM
MET WITH:Zhanna Davtian - LicenseeTIME VISIT/
INSPECTION COMPLETED:
12:00 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) Quoc Huynh arrived at the facility unannounced to conduct a required annual inspection. LPA arrived at the facility at 9:25AM, met with the facility Licensee Zhanna Davtian and explained the purpose of the visit.

LPA Huynh and Licensee conducted a tour of the physical plant at 9:30AM to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. 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 facility maintained a comfortable temperature throughout the visit. Smoke and carbon monoxide detectors were tested at 9:40AM and were operational. The fire extinguisher was fully charged and purchased on 02/24/2025. The LPA observed required postings on hallways and night lights throughout the facility.

KITCHEN: Knives are stored inaccessible in a drawer under the sink. Kitchen appliances were in operable condition. The facility has enough supply of perishable and non-perishable food. Freezer and refrigerator were stocked with a variety of foods. Prepared foods were safely covered with lids and labeled appropriately.

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: 04/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/04/2025
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: BLUE HORIZON
FACILITY NUMBER: 197609317
VISIT DATE: 04/04/2025
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
GARAGE: An adequate supply of emergency food and water supply for six residents and two staff were observed in the garage, which is locked at all times. Facility files and medications are stored in the garage and are locked.

BEDROOMS: The facility has three bedrooms; Room #1 is shared, Room #2 is private, and Room #3 is shared and cleared for non-ambulatory residents. Bedrooms were furnished appropriately with sufficient lighting and an extra supply of bed linens stored in the hallways.

BATHROOMS: There are two bathrooms; one in Room #3 and one designated for shared resident and visitor use. Residents’ bathrooms were observed to be in clean condition with grab bars and non-skid mats available. Hand washing signs were displayed, and sufficient amounts of soap and paper products were supplied in each restroom. Hot water temperature was measured at 113.6 degrees F, which is within the required range.

OUTDOOR AREA: Backyard has a shaded patio equipped with outdoor furniture in good condition for residents’ use. There is one automated driveway gate for vehicles and one entry/exit gate.

RECORDS: Records review began at 10:00AM. 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 training. All files were in order.

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

DATE: 04/04/2025
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: BLUE HORIZON
FACILITY NUMBER: 197609317
VISIT DATE: 04/04/2025
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
MEDICATIONS: Medications review began at 11:15AM; medications are centrally stored and kept inaccessible in the garage. Two out of six residents’ medications were reviewed. Medications are properly documented on the centrally stored medications and destruction record. No errors observed during the medication review.

INFECTION CONTROL/EMERGENCY DISASTER PLAN: The facility has an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. LPA reviewed the facility’s infection control plan and emergency disaster plan. Both documents were observed to be complete and reviewed annually. Emergency disaster drills are conducted quarterly, with the last drill documented on 02/01/2025.

One staff and one resident were interviewed during today’s visit. No complaints noted.

No deficiencies cited at this time. Exit interview conducted. A copy of the report was issued.
NAME OF LICENSING PROGRAM MANAGER: Kristin Heffernan
NAME OF LICENSING PROGRAM ANALYST: Quoc Huynh
LICENSING PROGRAM ANALYST SIGNATURE:

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

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