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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610165
Report Date: 05/12/2025
Date Signed: 05/12/2025 05:36:35 PM

Document Has Been Signed on 05/12/2025 05:36 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 S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:MCNULTY VILLAFACILITY NUMBER:
197610165
ADMINISTRATOR/
DIRECTOR:		WOOD, CHERIEFACILITY TYPE:
740
ADDRESS:20724 MCNULTY PL.TELEPHONE:
(818) 395-6037
CITY:CANOGA PARKSTATE: CAZIP CODE:
91306
CAPACITY: 6CENSUS: 6DATE:
05/12/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:00 PM
MET WITH:Wood Cherie - AdministratorTIME VISIT/
INSPECTION COMPLETED:
05:00 PM
NARRATIVE
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On 5/12/25 at approximately 12:00pm an unannounced annual visit was conducted by Licensing Program Analyst (LPA) Perchui Milena Khurshudyan. Upon arrival, LPA met with the Caregiver Rina Bayani, who granted access to the facility. LPA introduced herself by showing her badge and explained the reason for the visit. Shortly after the Administrator, Wood Cherie arrived and helped with staff/residents’ files and medications.

During today's visit, LPA conducted a physical plant walk through, at approximately 12:55pm, to ensure that the facility is in compliance with rules and regulations under California Code of Regulations, Title 22.The following was observed: The facility is a single-story home and is licensed for capacity of six (6) residents, of which four (4) may be non-ambulatory and of which fire clearance for one (1) Bedridden. Facility also has a hospice waiver for four (4) residents. There are five (5) bedrooms of which four (4) are designated for residents’ use. All bedrooms observed to be appropriately furnished and have appropriate lighting. There are two (2) bathrooms in the facility designated for residents’ and staff use. LPA observed bathrooms have soap, paper towels and hand washing signs. The hot water temperature measured at 1:13pm to be 136°F. Extra towels and linens were readily available in the linen closet located in the hallway. There are grab bars for each toilet and shower, bathrooms have non-skid mats. All trash cans in bathrooms had fitted lids to protect from cross contamination.

LPA observed facility alarms were present on all exit doors, however, the signals were off / Non-operational.

SMOKE DETECTORS/CARBON MONOXIDE. The smoke detectors and carbon monoxide are hard wired, inter-connected and were located throughout the facility. At 3:30pm they were tested and observed to be operational. The facility has one (1) fire extinguisher that was last purchased on 5/12/2025.

Continue on LIC809-C

NAME OF LICENSING PROGRAM MANAGER: Nichelle Gillyard
NAME OF LICENSING PROGRAM ANALYST: Perchui Khurshudyan
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/12/2025
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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Document Has Been Signed on 05/12/2025 05:36 PM - It Cannot Be Edited


Created By: Perchui Khurshudyan On 05/12/2025 at 03:49 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., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: MCNULTY VILLA
FACILITY NUMBER: 197610165

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/12/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space and Access
(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage.

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. LPA observed a cleaning solution in the backyard area available to residents in care. This poses an immediate health, safety, or personal rights risk to persons in care.
POC Due Date: 05/12/2025
Plan of Correction
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Lhe licensee immediately moved and stored cleaning solution inside the staff room, which is locked at all times.
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.
Nichelle Gillyard
NAME OF LICENSING PROGRAM MANAGER:
Perchui Khurshudyan
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/12/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/12/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/12/2025 05:36 PM - It Cannot Be Edited


Created By: Perchui Khurshudyan On 05/12/2025 at 03:49 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., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: MCNULTY VILLA
FACILITY NUMBER: 197610165

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/12/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
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, LPA measured the hot water in bathrooms to be 136F, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/16/2025
Plan of Correction
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Licensee/ Administrator will adjust the water temperature by POC due date and will provide proof of water temperature.
Type B
Section Cited
CCR
87307(d)(6)
Personal Accommodations and Services
(6) All outdoor and indoor passageways and stairways shall be kept free of obstruction.

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 by having obstructions/ boxes, tools, broken furniture etc on emergency exit areas, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/13/2025
Plan of Correction
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Licensee immediately cleaned the obstructions which were present on emergency exit.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Nichelle Gillyard
NAME OF LICENSING PROGRAM MANAGER:
Perchui Khurshudyan
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/12/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/12/2025


LIC809 (FAS) - (06/04)
Page: 4 of 8
Document Has Been Signed on 05/12/2025 05:36 PM - It Cannot Be Edited


Created By: Perchui Khurshudyan On 05/12/2025 at 03:49 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., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: MCNULTY VILLA
FACILITY NUMBER: 197610165

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/12/2025

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. Staff files were incomplete and missing required forms. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/16/2025
Plan of Correction
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The licensee / Administrator will email missing forms and the entire employee file for LPA review by POC due date.
Type B
Section Cited
CCR
87555(b)(27)
General Food Service Requirements
(b) The following food service requirements shall apply: (27) All kitchen areas shall be kept clean and free of litter, rodents, vermin and insects.

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. LPA observed breakfast area is cluttered. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/16/2025
Plan of Correction
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The Licensee will provide a picture of a clean kitchen and breakfast area.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Nichelle Gillyard
NAME OF LICENSING PROGRAM MANAGER:
Perchui Khurshudyan
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/12/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/12/2025


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 S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: MCNULTY VILLA
FACILITY NUMBER: 197610165
VISIT DATE: 05/12/2025
NARRATIVE
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KITCHEN: The facility has a Kitchen area that is equipped with a refrigerator, microwave oven, dish washer and sink. The kitchen appliances and fixtures were functional. LPA observed the kitchen area and found the refrigerator to be broken. LPA was informed by the Administrator that new refrigerator is purchased and will be replaced on 5/13/2025. There was sufficient stock of one-week non-perishable foods and two days of perishable foods. Frozen foods are properly wrapped and stored. Food storage and preparation areas observed to be cluttered and unorganized. LPA observed that sharp objects were stored inside the kitchen cabinet locked and inaccessible to residents in care. Extra emergency food was also properly stored inside the kitchen cabinets. Temperature was comfortable it was measured at 2:35pm to be 76°F.

MEDICATION: LPA observed centrally stored medication is locked inside the commercial cabinets located in the dining/living room area. First Aid kit was locked inside the storage cabinet, inaccessible to residents in care and it was checked by the LPA to be complete with new manual attached to it. Facility has two (2) staff for AM shift and two (2) awake caregivers for PM shift.

COMMON AREAS: LPA observed living room and a dining room that appeared generally clean and were properly furnished. No obstructions and or tripping hazards throughout the facility. Facility has land line; LPA checked its operational.

LAUNDRY ROOM: Laundry machines are located by the kitchen area and observed to be operational. LPA observed chemicals/detergent stored openly in the backyard, available to residents residing in the facility. LPA discussed the importance of keeping potentially dangerous items locked at all times.

SURROUNDING GROUNDS: LPA observed sufficient yard space with fenced backyard. LPA discussed the importance of maintaining the care and supervision to meet the needs of clients. Exit doors were unlocked however, obstructions were observed on the exit areas. The facility does not have a swimming pool or body of water. There is a garage in the property, which is currently being used for storage.

FILE REVIEW: Between 2:00pm to 3:30pm, LPA reviewed records and files of six (6) residents and four (4) staff/caregivers. A review of staff and resident records appeared to be not complete. There are no residents with prohibited conditions residing at the facility.

Continue on LIC809-C

NAME OF LICENSING PROGRAM MANAGER: Nichelle Gillyard
NAME OF LICENSING PROGRAM ANALYST: Perchui Khurshudyan
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2025
LIC809 (FAS) - (06/04)
Page: 6 of 8
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: MCNULTY VILLA
FACILITY NUMBER: 197610165
VISIT DATE: 05/12/2025
NARRATIVE
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An emergency exit plan/sketch along with other posting requirements are posted on the wall by the entrance area.

Medications Review: At approximately 12:35pm. LPA reviewed Centrally Stored Medication Destruction Records for proper documentation. Facility also maintains Medical Administration Records (MAR). PRN medications have written orders from a physician. Potentially dangerous items are kept inaccessible to residents in care.

LPA collected LIC500, LIC9020, copy of Liability Insurance Certificate.

Deficiencies issued during today’s visit.

Exit interview conducted and copy of this report signed and delivered.

NAME OF LICENSING PROGRAM MANAGER: Nichelle Gillyard
NAME OF LICENSING PROGRAM ANALYST: Perchui Khurshudyan
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2025
LIC809 (FAS) - (06/04)
Page: 7 of 8
Document Has Been Signed on 05/12/2025 05:36 PM - It Cannot Be Edited


Created By: Perchui Khurshudyan On 05/12/2025 at 04:46 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., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: MCNULTY VILLA
FACILITY NUMBER: 197610165

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/12/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

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. LPA observed the fridge was broken and the kitchen had clutter. This is a potential health, safety, or personal rights risk to persons in care.
POC Due Date: 05/16/2025
Plan of Correction
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The Licensee/Administrator will clean the kitchen area and will provide the new fridge receipt and picture by 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.
Nichelle Gillyard
NAME OF LICENSING PROGRAM MANAGER:
Perchui Khurshudyan
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/12/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/12/2025


LIC809 (FAS) - (06/04)
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