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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609546
Report Date: 12/18/2025
Date Signed: 12/18/2025 06:42:52 PM

Document Has Been Signed on 12/18/2025 06:42 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:HMS HOMEFACILITY NUMBER:
197609546
ADMINISTRATOR/
DIRECTOR:		DAVTIAN, ZHANNAFACILITY TYPE:
740
ADDRESS:14650 RUNNYMEDE STTELEPHONE:
(818) 616-2345
CITY:VAN NUYSSTATE: CAZIP CODE:
91405
CAPACITY: 6CENSUS: 6DATE:
12/18/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:18 AM
MET WITH:Zhanna Davtian, AdministratorTIME VISIT/
INSPECTION COMPLETED:
06:50 PM
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Licensing Program Analyst (LPA) Christine Yee conducted an unannounced required Annual Inspection using the complete CARE Inspection Tool and met with Zhanna Davtian, Administrator. The reason for today's visit was explained.

The facility is a single storey family home consisting of a living room, a dining room, a kitchen, 4 resident bedrooms, 3 full bathrooms and a attached garage. The bathroom located by the kitchen is designated for staff us. Previously located along the left side of the home and directly behind the garage was a fenced in swimming pool that has since been fenced off as part of the property for the ADU. The ADU has a separate address of 14648 Runnymede Street and is not part of the facility operations. The home is fire cleared for 5 NON-AMBULATORY and 1 bedridden resident. Bedroom #3 is designated for bedridden use.

On today's visit, all 12 domains of the CARE Inspection tool was reviewed. Also reviewed were 6 resident and 7 staff files. A tour of the physical plant, inside and outside, was conducted and the following were observed:
  • the living room and dining room were furnished with the appropriate furniture for 6 residents. The fireplace in the living room was covered with a fire screen.
  • Bedroom #1 and Bedroom #3 were observed with 2 each of the following - hospital beds, chairs, night stands, lamps and a shared dresser and closet.


continued on LIC809-C
NAME OF LICENSING PROGRAM MANAGER: Kristin Heffernan
NAME OF LICENSING PROGRAM ANALYST: Christine Yee
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 12/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/18/2025
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)
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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: HMS HOME
FACILITY NUMBER: 197609546
VISIT DATE: 12/18/2025
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  • Bedroom #2 and bedroom #4 were observed with 1 each of the following: hospital bed, chair, night stand, lamp, dresser and a closet.
  • the beds were observed with a mattress pad, fitted sheet and a comforter. Flat sheets were not observed per resident preference.
  • Extra bed linens, towels and blankets were observed in the walk in linen closet located in the hall way.
  • the kitchen is equipped with a stove, refrigerator, dishwasher and 2 microwaves. Knives are stored in a locked wooden cash kept in a kitchen drawer.
  • sufficient perishable foods for a minimum of 2 days and non-perishable foods for a minimum of 7 days were observed maintained on the premises.
  • The laundry room, located by the kitchen was observed with a washing machine and dryer. Cleaning supplies, detergents and chemicals are stored in a locked cabinet in the laundry room and in the outside shed.
  • All 3 bathrooms are equipped with a shower stall, toilet, grab bars, toilet risers, shower chairs, slip resistant mats and a single sink except the bathroom in the back, between bedroom #2 and bedroom #3, was observed with 2 sinks. Water temperature tested in the back bathroom read 123.7 degrees Fahrenheit and the front bathroom read 119.7 degrees Fahrenheit..
  • The hardwired smoke detectors and the combination detectors were tested and all were operational.
  • The only fire extinguisher located by the front door was purchased on 2/24/25.
  • The auditory devices on all four outside exiting doors were tested and were operational.
  • The first aid kit and first aid manual was reviewed and met requirements.
  • Medications and facility files were observed in 2 locked metal filing cabinets.
  • All staff have current first aid training.
  • The facility has the required general liability insurance and surety bond.
  • The required posting were observed
  • The backyard was observed with a table, chairs and a umbrella for outside activity. The back gate was observed with no locks. Also observed in the backyard was a storage shed. Trash cans were on the curb for trash pick up. Dried leaves were observed in the back and front yard due to the strong winds, otherwise the outside areas are well maintained.


Deficiencies cited under California Code of Regulations, Title 22, Division 6, Chapter 8
Exit interview was conducted, Appeals Rights discussed and a copy was provided.
NAME OF LICENSING PROGRAM MANAGER: Kristin Heffernan
NAME OF LICENSING PROGRAM ANALYST: Christine Yee
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/18/2025
LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 12/18/2025 06:42 PM - It Cannot Be Edited


Created By: Christine Yee On 12/18/2025 at 06:21 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: HMS HOME
FACILITY NUMBER: 197609546

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/18/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
Maintenance and Operations: 87303(e)(2) Water supplies and plumbing fixtures shall be maintained as follows:
(2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C)

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 the water temperature tested in the back bathroom, by Bedroom #3, the water temperature was tested and read 123.7 degreens Fahrenheit which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/19/2025
Plan of Correction
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The Licensee will adjust the thermostat to ensure that the water temperature for the water used by the residents is within Title 22 requirements of 105 to 120 degrees Fahrenheits. Licensee will provide evidence that the facility has corrected the deficiency or will self ceritify that the water temperature is within Title 22 requirements by 12/19/25.
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: 12/18/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/18/2025


LIC809 (FAS) - (06/04)
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