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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610044
Report Date: 09/16/2025
Date Signed: 09/16/2025 06:22:51 PM

Document Has Been Signed on 09/16/2025 06:22 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: 5DATE:
09/16/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:44 AM
MET WITH:Mary Petikyan, AdministratorTIME VISIT/
INSPECTION COMPLETED:
06:30 PM
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Licensing Program Analyst (LPA) Christine Yee conducted an unannounced required Annual Inspection using the complete CARE Inspection Tool and was let into the facility by Kristina Zamkotidou, Staff. Staff contacted Mary Petikyan, Administrator via telephone and she arrived at 11:03am to conduct the visit. The reason for today's visit was explained.

The facility is a single storey family home consisting of a living room, dining room, kitchen, 4 bedrooms, 3 full bathrooms and a attached garage. The facility is fire cleared for 5 NON-AMBULATORY and 1 BEDRIDDEN resident. Bedroom #1 is designated for bedridden use. The facility is approved for 2 hospice waivers. There are no bodies of water on the premises.

During today's visit all 12 domains of the CARE Inspection Tool was reviewed, 5 resident files and 8 staff files were reviewed. A tour of the physical plant, inside and outside, was conducted.

The following were observed on today's visit:
  • The dining room, living room and kitchen are equipped/furnished with the appropriate furniture and equipment for it's designated use.
  • Bedroom #1 and Bedroom #4 were observed with 2 hospital beds, 2 night stands, 2 lamps, 2 chairs and a shared dresser. Bedroom #1 has 2 portable closets and Bedroom #4 has a built in closet and a portable closet. The windows and outside exiting doors have blinds for privacy. The auditory devices on the doors were tested and were operational. Located inside Bedroom #4 is a private bathroom equipped


continued on LIC809-C
NAME OF LICENSING PROGRAM MANAGER: Kristin Heffernan
NAME OF LICENSING PROGRAM ANALYST: Christine Yee
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/16/2025
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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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: MARY'S CHATEAU
FACILITY NUMBER: 197610044
VISIT DATE: 09/16/2025
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  • with a shower, a sink, toilet with a riser, grab bars and a slip resistant mat. Water temperature was tested and read 109.5 degrees Fahrenheit.
  • Bedrooms #2 and Bedroom #3 were observed with 1 hospital bed, a night stand, a lamp, a chair, a dresser and a built in closet. Bedroom #2 has an outside exiting door that leads to a ramp and is equipped with an auditory device and was operational.
  • Located inside Bedroom #2 is a private bathroom equipped with a walk in shower, toilet, a sink, grab bars and a slip resistant mat. Water temperature was tested and read 118.9 degrees Fahrenheit.
  • The common bathroom located by the laundry closet is equipped with a walk in shower, chair, sink, toilet, grab bars and a slip resistant mat. Water temperature taken read 114.6 degrees Fahrenheit.
  • The laundry closet was observed with a stacked washer and dryer.
  • Extra Linens, towels and blankets were observed in the hallway closet.
  • The facility has current general liability insurance that meets Title 2 requirements.
  • The garage was observed to be used for storage of incontinent products, 30 gallons of water, an extra refrigerator with meats, fruits and vegetables and emergency rations and extra wheel chairs, sofa and staff clothing.
  • Sufficient perishable foods for a minimum of days and non-perishable foods for a minimum of 7 days were observed. The facility also maintains 2 buckets of emergency food rations.
  • The facility has 2 fire extinguishers - one located in the dining room and one by the door to the garage. Both were purchased on 4/24/25.
  • The first aid kit met Title 22 requirements. First aid manual was observed.
  • The hardwired smoke detectors located inside the resident bedroom and the combination smoke/carbon monoxide detector located in the resident room hallway and the living room were tested and were operational. However, the fire rated door located between the resident rooms and living room did not shut completely.
  • Per tour of the backyard, a table with an umbrella, chairs and wicker sofa and armchair were observed.
  • Trash cans located along the right side of the home were observed in good condition and were tightly sealed.
  • The front and back yard were observed to be clean of debris except for fallen leaves.


continued on LIC809-C
NAME OF LICENSING PROGRAM MANAGER: Kristin Heffernan
NAME OF LICENSING PROGRAM ANALYST: Christine Yee
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2025
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: MARY'S CHATEAU
FACILITY NUMBER: 197610044
VISIT DATE: 09/16/2025
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  • no bodies of water were observed on the premises.

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: 09/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/16/2025 06:22 PM - It Cannot Be Edited


Created By: Christine Yee On 09/16/2025 at 05:56 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: MARY'S CHATEAU
FACILITY NUMBER: 197610044

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/16/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87203(a)
87203 Fire Safety
All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic.

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 it was observed during test of the hard wired smoke detectors and combination smoke/carbon monoxide detectors that the fire rated door located between the resident rooms and the living room failed to shut completedly] which poses an immediate health, safety or personal rights risk to persons in care
POC Due Date: 09/17/2025
Plan of Correction
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The Licensee will ensure that the fire rated doors installed in the bedroom areas are inspected regularly to ensure that in case of a fire that the doors shut tightly and completely tdelay and prevent the spread of fire to allow residents to evacuate safely and prevent any loss of life. The Licensee will repair the door immediately and provide evidence of repairs. ***********the defect with the fire rated door was corrected at the time of this visit*************
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: 09/16/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/16/2025


LIC809 (FAS) - (06/04)
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