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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610177
Report Date: 07/30/2024
Date Signed: 07/30/2024 02:32:37 PM

Document Has Been Signed on 07/30/2024 02:32 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.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:ANNA'S HOME & PARADISEFACILITY NUMBER:
197610177
ADMINISTRATOR/
DIRECTOR:		ARMENYAN, ANNAFACILITY TYPE:
740
ADDRESS:23463 HAYNES STTELEPHONE:
(323) 660-0001
CITY:WEST HILLSSTATE: CAZIP CODE:
91307
CAPACITY: 6CENSUS: 5DATE:
07/30/2024
TYPE OF VISIT:OfficeUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:Anna ArmenyanTIME VISIT/
INSPECTION COMPLETED:
02:40 PM
NARRATIVE
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At 1:00 p.m. on 07/30/2024, Regional Manager (RM) Angela Whittaker, Licensing Program Manager (LPM) Naira Margaryan, Licensing Program Analyst (LPA) Nicholas Reed, Licensee Anna Armenyan, and Consultant Viktorya Hayrapetyan met at the Woodland Hills-South Adult and Senior Care Regional Office for a Non-Compliance Conference (NCC).

Today's NCC was held for a substantiated allegation of unlicensed care being provided on 07/02/2024 at 7312 Cantaloupe Ave, Van Nuys CA 91405. In addition, four (04) deficiencies were cited during an annual visit on 07/19/2024.

After review of the facility file and discussion of recent violations, the Department has determined to issue an additional deficiency for insufficient administrator qualifications due to the nature of the recent violations.

Deficiency is issued on the corresponding LIC 809-D page.

Exit interview conducted. Appeal rights discussed. Copy of report provided.

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Nicholas Reed
LICENSING EVALUATOR SIGNATURE: DATE: 07/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/30/2024
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 2
Document Has Been Signed on 07/30/2024 02:32 PM - It Cannot Be Edited


Created By: Nicholas Reed On 07/30/2024 at 01:15 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., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: ANNA'S HOME & PARADISE
FACILITY NUMBER: 197610177

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/30/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/09/2024
Section Cited
CCR
87405(d)(1)

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87405 Administrator - Qualifications and Duties - (d) The administrator shall have the qualifications... (1) Knowledge of the requirements for providing care and supervision appropriate to the residents.
This requirement is not met as evidenced by:
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Licensee has agreed to enter into a Compliance Plan and accept a Technical Support Program referral for further education by the POC due date.
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Based on interviews and observation, the licensee did not comply with the section cited above which poses a potential Health, Safety, or Personal Rights risk to persons in care.
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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:Naira Margaryan
LICENSING EVALUATOR NAME:Nicholas Reed
LICENSING EVALUATOR SIGNATURE:
DATE: 07/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/30/2024


LIC809 (FAS) - (06/04)
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