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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609980
Report Date: 05/30/2025
Date Signed: 05/30/2025 04:34:13 PM

Document Has Been Signed on 05/30/2025 04:34 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: 4DATE:
05/30/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:15 AM
MET WITH:Emma AvetisyanTIME VISIT/
INSPECTION COMPLETED:
04:45 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) Trevor Byrne conducted unannounced case management deficiencies visit at the facility today. LPA arrived to the facility at 10:15 AM. LPA met with the facility staff, staff #1 (S1) who contacted the facility Administrator Emma Avetisyan via telephone call. The Administrator arrived to the facility at approximately 12:30 PM. Entrance interview conducted and the reason for the visit was explained.

During today’s visit, the LPA conducted a physical plant tour to ensure there are no health and safety hazards, collected copies of pertinent documents, conducted a medication audit for one (1) resident, and conducted interviews with the Administrator, one (1) staff member, one (1)resident, and one (1) witness between 10:20 AM and 02:00 PM

During the physical plant tour LPA observed the flooring near the exit located in the kitchen to be bubbling up, held together with tape, and in disrepair. Additionally, LPA observed the closet door located in bedroom # 2 to be detached from the railing and in disrepair. LPA observed a light switch cover in the shared resident bathroom to be broken and had sharp exposed plastic. LPA informed the Administrator of the items that were in disrepair and the Administrator agreed to perform the needed repairs to the identified items.

During an interview with S1 and the Administrator LPA was informed that resident #1 (R1) was recently hospitalized after a medical incident. LPA reviewed the facility file and their inbox and did not observe an incident report submitted for the hospitalization of R1. LPA informed the Administrator that incidents must be reported to Community Care Licensing Division no later than seven days following the occurrence of the incident. The Administrator expressed understanding and submitted a report for the incident at the time of the inspection.

Continued on LIC 809C.

NAME OF LICENSING PROGRAM MANAGER: Kasandra Lopez
NAME OF LICENSING PROGRAM ANALYST: Trevor Byrne
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/30/2025
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 6
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 6
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: 05/30/2025
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
During medication review LPA observed R1's medications. LPA observed one (1) medication to not be listed on R1's centrally stored medication and destruction record sheet (CSMDR). LPA informed the Administrator of the discrepancy. The Administrator agreed to conduct a medication audit and submit an accurate CSMDR for R1 to CCLD.

During file review LPA observed the resident file for resident #2 (R2). LPA observed this resident’s physician report to identify the resident as “Ambulatory” and “Able to feed self”. During the visit LPA observed R2 to be utilizing a wheelchair and being fed by S1. LPA asked the Administrator about the condition of R2. The Administrator confirmed that R2 was a Non-Ambulatory resident based on their physical condition and mental diagnosis. The Administrator stated that this is a recent change of condition, and the facility had not yet obtained an updated physician report for the change in condition. LPA informed the Administrator that the facility’s fire clearance does not allow them to accept or retain Non-Ambulatory residents. LPA informed the Administrator that this is a violation of their fire clearance and poses an immediate safety risk to clients in care. LPA informed the Administrator that this is a zero-tolerance violation and an immediate civil penalty in the amount of $500 will be assessed on today’s date (05/30/2025). The Administrator expressed understanding and confirmed that they will contact the local fire department and notify them that they have a Non-Ambulatory resident. Additionally, the Administrator confirmed that the resident would be relocated to a licensed facility that has an appropriate fire clearance to care for Non-Ambulatory residents.

During the file review for R2 LPA observed R2’s physician’s report to be missing a negative TB test. LPA asked the Administrator if they were able to provide proof of a negative TB test for the identified resident. The Administrator stated that the physician’s report was transferred from another facility and the facility had not yet obtained an updated physician report for R2. LPA informed the Administrator that they were recently cited for a violation of CCR 87458(c)(1)(A) on 02/20/2025. LPA informed the Administrator that this is a repeat violation of the same regulation within a 12-month period and a civil penalty in the amount of $250 will be assessed on today’s date (05/30/2025) for a repeat violation.


The Administrator was unavailable 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 and civil penalties were cited (refer to LIC 809-D): Exit interview conducted and copy of the report was issued and appeal rights provided.

NAME OF LICENSING PROGRAM MANAGER: Kasandra Lopez
NAME OF LICENSING PROGRAM ANALYST: Trevor Byrne
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2025
LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 05/30/2025 04:34 PM - It Cannot Be Edited


Created By: Trevor Byrne On 05/30/2025 at 02:58 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: 05/30/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/31/2025
Section Cited
CCR
87202(a)

1
2
3
4
5
6
7
87202 Fire Clearance
(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal...
This requirement is not met as evidenced by:
1
2
3
4
5
6
7
The Administrator stated that they will contact the local fire department and notify them that they have a Non-Ambulatory resident. Additionally, the Administrator confirmed that the resident would be issued an eviction notice and be relocated to an appropriate facility.
8
9
10
11
12
13
14
Based on observation and file review the Licensee did not comply with the section cited above as one resident was observed to be non-ambulatory for which the facility does not have an approved fire clearance which poses an immediate safety risk to clients in care.
8
9
10
11
12
13
14
Licensee will submit their plan on how they will evacuate the identified resident safely from the facility in the event of a fire or emergency. Licensee will submit proof of corrections no later than POC due date.
Type B
06/13/2025
Section Cited
CCR87458(c)(1)(A)

1
2
3
4
5
6
7
87458 Medical Assessment
(c) The medical assessment shall include, but not be limited to:
(1) A physical examination of the resident indicating...all of the following:
(A) Communicable tuberculosis.
This requirement is not met as evidenced by:
1
2
3
4
5
6
7
The Licensee will obtain an updated physician report for R2 confirming a negative TB test. The Licensee may also satisfy this POC via the eviction of R2 due to the fire clearance violation mentioned above. Licensee will submit proof of corrections no later than POC due date.
8
9
10
11
12
13
14
Based on file review the Licensee did not comply with the section cited above as one resident file was observed to be missing proof of a negative TB test which poses an potential health risk to clients in care.
8
9
10
11
12
13
14
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Kasandra Lopez
NAME OF LICENSING PROGRAM MANAGER:
Trevor Byrne
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/30/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/30/2025


LIC809 (FAS) - (06/04)
Page: 4 of 6
Document Has Been Signed on 05/30/2025 04:34 PM - It Cannot Be Edited


Created By: Trevor Byrne On 05/30/2025 at 03:08 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: 05/30/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/13/2025
Section Cited
CCR
87211(a)(1)

1
2
3
4
5
6
7
87211 Reporting Requirements
(a) Each licensee shall furnish to the licensing agency...
(1) A written report shall be submitted to the licensing agency... within seven days of the occurrence...
This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Administrator submitted R1's incident report at the time of the visit. Licensee will submit an incident report for R2 and will submit a statement of understanding confirming that they understand the importance of submitting reports in a timely manner.
8
9
10
11
12
13
14
Based on file review and interview the Licensee did not comply with the section cited above as incident reports for R1's hospitalization and R2's change of condition were not submitted to CCLD which poses a potential health, safety, or personal rights risk to clients in care.
8
9
10
11
12
13
14
 Licensee will submit these items no later than POC due date.
Type B
06/13/2025
Section Cited
CCR87463(b)

1
2
3
4
5
6
7
87463 Reappraisals
(b) The reappraisal shall document significant changes in the resident's physical, mental, cognitive, behavioral, or functional condition...
This requirement is not met as evidenced by:
1
2
3
4
5
6
7
The Licensee will obtain an updated physician report for R2. The Licensee may also satisfy this POC via the eviction of R2 due to the fire clearance violation. Licensee will submit proof of corrections no later than POC due date.
8
9
10
11
12
13
14
Based on file review and observation the Licensee did not comply with the section cited above as R2 had a change of condition that was not reflected on their physician report which poses a potential health and safety risk to clients in care.
8
9
10
11
12
13
14
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Kasandra Lopez
NAME OF LICENSING PROGRAM MANAGER:
Trevor Byrne
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/30/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/30/2025


LIC809 (FAS) - (06/04)
Page: 5 of 6
Document Has Been Signed on 05/30/2025 04:34 PM - It Cannot Be Edited


Created By: Trevor Byrne On 05/30/2025 at 03:15 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: 05/30/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/13/2025
Section Cited
CCR
87303(a)

1
2
3
4
5
6
7
87303 Maintenance and Operation
(a) The facility shall be clean, safe, sanitary and in good repair at all times...
This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Licensee will submit proof of completed repairs for the identified items. Licensee will submit proof no later than POC due date.
8
9
10
11
12
13
14
Based on observation the Licensee did not comply with the section cited above as the flooring in the kitchen near the exit, the closet door in room # 2, and the light switch cover in the shared resident bathroom were in disrepair which poses a potential health and safety risk to clients in care.
8
9
10
11
12
13
14
Type B
06/13/2025
Section Cited
CCR87465(h)(6)

1
2
3
4
5
6
7
87465 Incidental Medical and Dental Care
(h) The following... shall apply...
(6) The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained...
This requirement is not met as evidenced by:
1
2
3
4
5
6
7
The Administrator agreed to conduct a medication audit and submit an accurate CSMDR for R1 to CCLD no later than POC due date.
8
9
10
11
12
13
14
Based on record review the licensee did not comply with the section cited above as one medication prescribed to R1 was not logged on R1's CSMDR which poses a potential health risk to clients in care.
8
9
10
11
12
13
14
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Kasandra Lopez
NAME OF LICENSING PROGRAM MANAGER:
Trevor Byrne
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/30/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/30/2025


LIC809 (FAS) - (06/04)
Page: 6 of 6