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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610044
Report Date: 09/06/2024
Date Signed: 09/06/2024 04:35:16 PM

Document Has Been Signed on 09/06/2024 04:35 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:MARY'S CHATEAUFACILITY NUMBER:
197610044
ADMINISTRATOR/
DIRECTOR:		PETIKYAN, MARYFACILITY TYPE:
740
ADDRESS:13912 VALERIO STREETTELEPHONE:
(323) 333-8105
CITY:VAN NUYSSTATE: CAZIP CODE:
91405
CAPACITY: 6CENSUS: 6DATE:
09/06/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:47 AM
MET WITH:MARY PETIKYANTIME VISIT/
INSPECTION COMPLETED:
04:40 PM
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Licensing Program Analysts (LPA) Erica Mosley arrived at the facility unannounced to conduct a required annual visit and entered the facility at 11:00 a.m. Upon arrival, LPA Mosley was greeted by staff and called the administrator to inform them of the visit. The administrator arrived shortly thereafter. The LPA met with Administrator MARY PETIKYAN and explained the reason for the visit. The LPA toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations.

The facility is a single-story family home consisting of a living room, dining room, kitchen, 4 bedrooms, 3 full bathrooms and an attached garage. The facility is fire cleared for 5 NON-AMBULATORY and 1 BEDRIDDEN resident.

KITCHEN: The LPA inspected the kitchen/food service area at 11:17 a.m. Knives and sharps were observed in a locked cabinet. Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. Refrigerator and food pantry were checked for proper labels and expiration dates. The kitchen faucet was measured for hot water temperature, and it measured 110.9 degrees Fahrenheit at 11:33 a.m.

COMMON AREAS: At the time of the visit, furniture in the common areas was observed to be in good condition. The facility maintained a comfortable temperature. At 2:42 p.m., smoke detector(s) and carbon monoxide detector were tested and operational at the time of the visit. The facility has two (2) fire extinguishers that were observed and fully charged on 07/12/2024. The LPA observed required postings throughout the common space. The last emergency disaster drill took place on 08/02/2024. Activities were observed in the common areas.

Report Continued on LIC 809C...

SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Erica Mosley
LICENSING EVALUATOR SIGNATURE: DATE: 09/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/06/2024
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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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: MARY'S CHATEAU
FACILITY NUMBER: 197610044
VISIT DATE: 09/06/2024
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Report Continued from LIC 809...
RESTROOMS: The three (3) resident restrooms one (1) shared and two (2) private and were clean, sanitary and in operating condition with grab bars and non-skid surfaces. The bathrooms were sufficiently stocked with supplies and paper towels. The hot water temperature was measured; the shared bathroom measured at 112.9 degrees Fahrenheit at 11:20 a.m. The hot water temperature in the private bathroom was measured between approximately 11:20 a.m. and 11:40 a.m. and measured at 111.8 and 115.2 degrees Fahrenheit within the required range.

BEDROOMS: There are 4 (four) total bedrooms in the facility; two (2) are designated as a shared room, two (2) are designated as private resident rooms. All resident rooms were observed to be furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting.

GARAGE/BACKYARD: The garage is maintained locked at all times. There is a washer and dryer on premises. Laundry detergent was observed in the locked garage. LPA observed an adequate amount of emergency food and water. Cleaning supplies are kept in the garage locked and inaccessible to residents in care. The backyard has a covered patio area with patio furniture including a table and chairs for resident use. All passageways were observed to be clear. LPA observed one (1) self-latching gate. There were no bodies of water noted at the time of the visit.



MEDICATIONS: Medications review began at approximately 1:55 p.m. The medications are locked in a cabinet adjacent to the kitchen. Medications for six (6) residents were reviewed. Medications reviewed were found to be self administered as prescribed and documented on the centrally stored medication and destruction records.

RECORDS: Resident Records were reviewed beginning at 11:49 a.m. and personnel records at 12:30 p.m. Six (6) resident files were reviewed for, but not limited to, the following: signed admission agreements, current medical assessments with TB results, LIC627(c) Consent for Treatment form, and current needs and services plan.

Report Continued on LIC 809C...

SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Erica Mosley
LICENSING EVALUATOR SIGNATURE:

DATE: 09/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3
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: MARY'S CHATEAU
FACILITY NUMBER: 197610044
VISIT DATE: 09/06/2024
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Report Continued from LIC 809C...

Six (6) personnel files including the Administrator’s file were reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All records were in order.

INTERVIEWS: Three (3) staff interviews were conducted. Four (4) resident interviews were attempted, two (2) interviews were conducted. One (1) family member/ visitor interview was conducted at the time of the visit.

No deficiencies were cited during today’s inspection. Exit interview conducted. A copy of the report was provided.

SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Erica Mosley
LICENSING EVALUATOR SIGNATURE:

DATE: 09/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2024
LIC809 (FAS) - (06/04)
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