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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609980
Report Date: 02/20/2025
Date Signed: 02/20/2025 03:36:08 PM

Document Has Been Signed on 02/20/2025 03:36 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:AMY'S PARADISE HOME OF ANGELS INC.FACILITY NUMBER:
197609980
ADMINISTRATOR/
DIRECTOR:		EMMA AVETISYANFACILITY TYPE:
740
ADDRESS:11950 ROSCOE BLVDTELEPHONE:
(310) 913-6161
CITY:NORTH HOLLYWOODSTATE: CAZIP CODE:
91605
CAPACITY: 6CENSUS: 6DATE:
02/20/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:03 AM
MET WITH:Emma ElazyanTIME VISIT/
INSPECTION COMPLETED:
03:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Trevor Byrne arrived at the facility unannounced to conduct a required annual visit at 09:03 AM. LPA met with facility staff member Emma Elazyan (S1) who contacted the facility administrator Emma Avetisyan. The Administrator informed LPA that they were unable to come to the facility at the time of the visit. Entrance interview conducted and the reason for the visit was explained.

Beginning at 09:10 AM, the LPA, along with S1 toured the physical plant areas inside and outside to ensure there are no health and safety hazards and that facility is in compliance with Title 22 Regulations. The following was observed:

KITCHEN: The LPA observed the kitchen area to be clean. Kitchen appliances appeared to be in operable condition. The facility has a sufficient supply of two (2) days perishable and seven (7) days non-perishable food. LPA observed a secured cabinet to contain knives and other sharp objects. LPA observed a secured cabinet to contain resident medications and a first aid kit. One (1) additional secured cabinet was observed to contain facility files. LPA observed a cabinet to contain adequate emergency food supplies. LPA observed a fire extinguisher mounted in the kitchen to be fully charged and purchased on 02/26/2024.

COMMON AREAS: This includes the living room, hallway, and dining area. The living room was observed to be clean and in good repair. The living room contained adequate seating for resident use. LPA observed the living room to contain a television and activities for resident use. LPA observed the dining area to be clean and properly furnished at the time of the visit. The dining area contains a dining table with adequate seating for resident use. LPA observed a hallway closet to contain extra linens. The facility’s fire and carbon monoxide alarms were tested at 09:47 AM. At 09:48 AM LPA observed the facility’s carbon monoxide alarm to be non-functional. All exits in the facility were observed to contain functioning auditory alarms.
Continued on LIC 809C.
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Trevor Byrne
LICENSING EVALUATOR SIGNATURE: DATE: 02/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/20/2025
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 8
Document Has Been Signed on 02/20/2025 03:36 PM - It Cannot Be Edited


Created By: Trevor Byrne On 02/20/2025 at 02:24 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: AMY'S PARADISE HOME OF ANGELS INC.
FACILITY NUMBER: 197609980

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/20/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1569.311
Regulations
Every residential care facility for the elderly shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 of Division 12. The department shall account for the presence of these detectors during inspections.

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 facility's carbon monoxide detector was non-functional at the time of the visit which poses an immediate health and safety risk to persons in care.
POC Due Date: 02/21/2025
Plan of Correction
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Licensee will submit proof of a functioning carbon monoxide detector to CCLD no later than POC due date.
Type A
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) 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 degrees C) and not more than 120 degree F (49 degrees 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 as the water temparature was measured between 138.2 and 140.4 degrees F which poses an immediate health risk to persons in care.
POC Due Date: 02/21/2025
Plan of Correction
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Licensee will submit proof of appropriate water temparature to CCLD no later than POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Kasandra Lopez
LICENSING EVALUATOR NAME:Trevor Byrne
LICENSING EVALUATOR SIGNATURE:
DATE: 02/20/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/20/2025


LIC809 (FAS) - (06/04)
Page: 2 of 8
Document Has Been Signed on 02/20/2025 03:36 PM - It Cannot Be Edited


Created By: Trevor Byrne On 02/20/2025 at 02:24 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: AMY'S PARADISE HOME OF ANGELS INC.
FACILITY NUMBER: 197609980

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/20/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.605
Other Provisions
On and after July 1, 2015, all residential care facilities for the elderly, except those facilities that are an integral part of a continuing care retirement community, shall maintain liability insurance covering injury to residents and guests in the amount of at least one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate, caused by the negligent acts or omissions to act of, or neglect by, the licensee or its employees.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above as the facility was unable to provide a copy of un-expired liability insurance at the time of the inspection which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/06/2025
Plan of Correction
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Licensee will submit proof of valid liability insurance to CCLD no later than POC due date.
Type B
Section Cited
CCR
87303(c)
Maintenance and Operation
(c) All window screens shall be clean and maintained in good repair.

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 three windows were observed to have screens missing or not properly installed which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/06/2025
Plan of Correction
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Licensee will submit proof of appropriate window screen repairs for the three identified windows to CCLD no later than POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Kasandra Lopez
LICENSING EVALUATOR NAME:Trevor Byrne
LICENSING EVALUATOR SIGNATURE:
DATE: 02/20/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/20/2025


LIC809 (FAS) - (06/04)
Page: 3 of 8
Document Has Been Signed on 02/20/2025 03:36 PM - It Cannot Be Edited


Created By: Trevor Byrne On 02/20/2025 at 02:24 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: AMY'S PARADISE HOME OF ANGELS INC.
FACILITY NUMBER: 197609980

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/20/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(a)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above as one employees file was observed to be missing their LIC 508 and one additional employee's file was observed to be missing their LIC 503 and a negative TB test which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/06/2025
Plan of Correction
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Licensee will submit the missing documentation for the identified employees to CCLD no later than POC due date.
Type B
Section Cited
CCR
87458(c)(1)(A)
Medical Assessment
(c) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the licensed medical professional's diagnosis or diagnoses and results of an examination for all of the following: (A) Communicable tuberculosis.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above as one resident's file was observed to be missing a negative TB test which poses a potential health risk to persons in care.
POC Due Date: 03/06/2025
Plan of Correction
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Licensee will submit proof of a negative TB test for the identified resident to CCLD no later than POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Kasandra Lopez
LICENSING EVALUATOR NAME:Trevor Byrne
LICENSING EVALUATOR SIGNATURE:
DATE: 02/20/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/20/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/20/2025 03:36 PM - It Cannot Be Edited


Created By: Trevor Byrne On 02/20/2025 at 02:24 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: AMY'S PARADISE HOME OF ANGELS INC.
FACILITY NUMBER: 197609980

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/20/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(d)
Other Provisions
(d) A facility shall review the plan annually and make updates as necessary, including changes in floor plans and the population served. The licensee or administrator shall sign and date documentation to indicate that the plan has been reviewed and updated as necessary.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above as the facility's emergency disaster plan was not reviewed annually which poses a potential safety risk to persons in care.
POC Due Date: 03/06/2025
Plan of Correction
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Licensee will submit a reviewed emergency disaster plan to CCLD no later than POC due date.
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.
SUPERVISOR'S NAME:Kasandra Lopez
LICENSING EVALUATOR NAME:Trevor Byrne
LICENSING EVALUATOR SIGNATURE:
DATE: 02/20/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/20/2025


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: AMY'S PARADISE HOME OF ANGELS INC.
FACILITY NUMBER: 197609980
VISIT DATE: 02/20/2025
NARRATIVE
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BEDROOMS: There are four (4) bedrooms in the facility; two (2) are a dual occupancy rooms and two (2) are single occupancy rooms. LPA and S1 toured all four (4) bedrooms. All resident rooms were observed to be furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting. Bedroom #2’s window was observed to be missing a window screen. Bedroom #1’s window screen was observed to be seated improperly in the frame which left an opening in the corner of the frame.

BATHROOMS: There are two (2) bathrooms at the facility. One (1) bathroom is designated as private resident bathroom, and one (1) bathroom is designated as a shared resident bathroom. Both resident bathrooms were observed to be clean and in good repair and were equipped with nonskid surfaces. Grab bars were observed in all resident showers and near all resident toilets, all were properly secured. The water temperature was measured between 138.2 and 140.4 degrees Fahrenheit, which outside of the range required by regulation. The private resident’s bathroom window screen was observed to be seated improperly in the frame which left an opening in the corner of the frame.

OUTDOOR SPACE: The facility has two (2) emergency exit gates. One (1) is located in the front yard and one (1) is located in the backyard; LPA observed clear passageways for emergency exit use. The facility has adequate shaded seating outdoors for resident use. LPA observed the facility’s backyard to contain two (2) additional refrigerators containing extra food items.

RECORD REVIEW: Record review began at 10:00 AM. Staff and resident records were reviewed for documents including, but not limited to: health screening, TB test, staff training records, fingerprint clearance, resident physician's report, needs and service appraisal, consent forms, and personal rights. Four (4) staff files were reviewed. One (1) staff file was observed to be missing the required LIC 508 Out-of-state disclosure sheet. One (1) staff file was observed to be missing the LIC 503 Health screening report – facility personnel and a negative TB test. Six (6) resident files were reviewed. One (1) resident file was observed to be missing a negative Tuberculosis (TB) test.

MEDICATION REVIEW: Medication review began at 11:45 AM. Medications for six (6) of six (6) residents were observed. All medications were stored properly and were appropriately documented on their respective centrally stored medication and destruction record sheets. Continued on LIC 809C.
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Trevor Byrne
LICENSING EVALUATOR SIGNATURE:

DATE: 02/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/20/2025
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: AMY'S PARADISE HOME OF ANGELS INC.
FACILITY NUMBER: 197609980
VISIT DATE: 02/20/2025
NARRATIVE
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INFECTION CONTROL/EMERGENCY DISASTER PLANNING: During today’s visit, the LPA reviewed the
facility's infection control practices and the facility's emergency disaster plan. The facility’s policies and procedures as it pertains to infection control are adequate. Emergency disaster drills are conducted quarterly; the facility’s last emergency disaster drill was conducted on 01/14/2025. The facility’s emergency disaster plan is adequate. The emergency disaster plan was last reviewed/updated by the Administrator on 06/22/2021 which is outside of the required annual timeframe. The infection control plan is reviewed/updated annually by the facility’s administrator.

INTERVIEWS: LPA interviewed two (2) residents. The residents interviewed stated that the staff treat them well and are attentive to their needs. Both residents had no concerns with the facility. One (1) staff interview was conducted. The staff member interviewed was knowledgeable on the resident’s rights, the forms of abuse, and the appropriate reporting procedures for suspected abuse.

During today’s visit LPA obtained a copy of the facility’s LIC 500 and resident roster. The facility was unable to provide a copy of valid liability insurance at the time of the inspection.

The facility Administrator was unable to come to the facility to sign this report but has designated S1 to sign on their behalf. This report was read to the Administrator via telephone call.

Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D): Exit interview conducted and copy of the report was issued and appeal rights provided.

SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Trevor Byrne
LICENSING EVALUATOR SIGNATURE:

DATE: 02/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/20/2025
LIC809 (FAS) - (06/04)
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