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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610349
Report Date: 01/13/2025
Date Signed: 01/13/2025 01:12:24 PM

Document Has Been Signed on 01/13/2025 01:12 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:HELIOTROPE ASSISTED LIVINGFACILITY NUMBER:
197610349
ADMINISTRATOR/
DIRECTOR:		PLOKHOVA, IRENFACILITY TYPE:
740
ADDRESS:16764 ROMAR ST.TELEPHONE:
(818) 635-1249
CITY:NORTH HILLSSTATE: CAZIP CODE:
91343
CAPACITY: 6CENSUS: 5DATE:
01/13/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:35 AM
MET WITH:Peter Atoyan- AdministratorTIME VISIT/
INSPECTION COMPLETED:
01:40 PM
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Licensing Program Analyst (LPA) Leslie Ngo-Castaneda conducted an annual required visit and inspection of the facility. LPA met with staff Ruzanna Manukyan and explained for the visit. At 10:16 AM Ruzanna Manukyan who is the designee arrived and met with LPA, explained the reason for the visit. At 10:30 AM licensee, Peter Atoyan, arrived and was explained the reason of the visit.

At 10:16 am, with the assistance of designee, LPA took a tour of the physical plant. Required postings were observed in the entry area. The smoke alarms are operational that are located each bedroom, the hallway and kitchen. There are carbon monoxide detectors that functions properly. The fire extinguisher is in the kitchen. The charge date is 4/11/2024. During the visit the facility is at 72 degrees Fahrenheit. The facility is fire cleared for six (06) non-ambulatory residents; one (1) may be bedridden for bedroom #4 and is cleared for four (4) hospice waiver.

Kitchen: The kitchen appliances and fixtures were functional. The kitchen has a working gas stove, faucet, freezer, refrigerator, and microwave. LPA found enough at least two (2) days perishable and seven (7) days non-perishable food at the facility that is properly stored. Frozen foods are wrap, dated, and stored properly as well. Knives were stored in a locked box in the kitchen counter-top. Food storage and preparation areas are clean and inaccessible to pests. Garbage cans have tight fitting covers. Cleaning supplies and aerosols that was found in the hallway cabinet was found to be unlock an accessible to residents. Deficiency will be cited in LIC 809-D. Laundry and other cleaning supplies were stored and locked away in the kitchen below the sink.


Continue to LIC 809-C
NAME OF LICENSING PROGRAM MANAGER: Nichelle Gillyard
NAME OF LICENSING PROGRAM ANALYST: Leslie Ngo-Castaneda
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 01/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/13/2025
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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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: HELIOTROPE ASSISTED LIVING
FACILITY NUMBER: 197610349
VISIT DATE: 01/13/2025
NARRATIVE
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Bathrooms: There are three (3) bathroom designated for residents' use. The bathrooms were properly supplied and had functional fixtures. Hot water temperature was measured at 105.1 degrees Fahrenheit for bathroom #1 located in the hallway across bedroom #1. Bathroom #2 by the end of the hallway and is used only for staff. Bathroom #3 is inside bedroom #3. Hot water temperature was measured at 105.3 degrees Fahrenheit. There was enough clean linen available in the cabinets in the hallway.

Common Areas: LPA toured all common areas of the facility. These included the living room and dining area for residents. The common areas were properly furnished. Residents dining table fits enough for six (6). LPA observed common areas to be very clean and tidy. LPA observed the floors to be in very good condition. No obstructions and or tripping hazards throughout the facility. Furniture in common area was observed to be in good repair. Office is located in the common area. Fireplace is close and block off for access. There are no issues with fire clearance.

Infection control: Facility mitigation plan to make sure licensee was following current infection control recommendations. LPA obtain a copy and reviewed the infection control plan during this visit.

Surrounding Grounds: Entry and exits were free of obstruction. There was furniture appropriate for outdoor use. The outdoor area was free of hazards. The facility does not have a swimming pool or body of water. There is no garage in the facility only a car port.

Laundry service: There is enough linen available to change weekly or more if need. Laundry is located outside the covered patio. Cleaning supplies are being stored in a locked cabinet in the kitchen area.

Staff Files: LPA also conducted a file review of staff records to ensure forms and training are up to date and compliance with licensing forms. Records were checked for expired or missing certificates and clearances: LPA conducted a file review of staff for criminal record clearances and current First Aid. The administrator file was reviewed for current first aid, fingerprint clearance, administrator certificate, and HIV/AIDS and TB training.

Continue to LIC 809-C
NAME OF LICENSING PROGRAM MANAGER: Nichelle Gillyard
NAME OF LICENSING PROGRAM ANALYST: Leslie Ngo-Castaneda
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 01/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/13/2025
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: HELIOTROPE ASSISTED LIVING
FACILITY NUMBER: 197610349
VISIT DATE: 01/13/2025
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This page is corrected due to appeal granted on 9.24.2025.

Bedrooms: There were four (4) bedrooms designated for residents' use. Bedroom #1 is shared but is used privately at the present. Bedroom #2 is empty and is used as a lounge area for the staff. Bedroom #3 is shared. Bedroom #4 is private for the residents were properly furnished with appropriate dresser, beddings, and linens with sufficient lighting. Although resident room smells like urine, it was not verified that resident was no incontinent.

Medications are in a centrally stored and locked place, including over-the-counter medicines; medications are properly labeled and checked for expiration dates. Each centrally stored prescription and PRN medication has been logged in the medications log with proper documentation from the clients’ doctor. Proper medication dispensing instruction are followed and checked for contamination. First-aid has all proper items and is current.

Resident records were reviewed for requirements and legibility: LPA reviewed client’s files for current appraisal. Planned activities are offered. R5 is missing TB test and MD report. Deficiency will be cited in LIC 809-D.

Facility is within CA code of Regulations Title 22 or Health and Safety Code. No deficiencies were found, exit interview conducted, copy of report has been issued and discussed.
NAME OF LICENSING PROGRAM MANAGER: Naira Margaryan
NAME OF LICENSING PROGRAM ANALYST: Leslie Ngo-Castaneda
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 01/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/13/2025
LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 01/13/2025 01:12 PM - It Cannot Be Edited


Created By: Leslie Ngo-Castaneda On 01/13/2025 at 12:06 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: HELIOTROPE ASSISTED LIVING
FACILITY NUMBER: 197610349

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/13/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87309(a)(1)
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. (1) Disinfectants, cleaning solutions, and poisonous substances shall be stored in areas separate from food supplies as specified in Section 87555, General Food Service Requirements.

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 in 1 out of 1 aerosol/ cleaning supplies were seen in closet that was unlock and accessible to the residents, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/14/2025
Plan of Correction
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Licensee needs to ensure cleaning supplies to be lock and not accessible to residents.
Type B
Section Cited
CCR
87458(c)(1)
Medical Assessment
(c) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the licensed medical professional's diagnosis or diagnoses and results of an examination for all of the following:

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 in 1 out of 1 R5 physician report was not available which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/27/2025
Plan of Correction
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R5 needs physician report and TB test before admission.
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:Nichelle Gillyard
LICENSING EVALUATOR NAME:Leslie Ngo-Castaneda
LICENSING EVALUATOR SIGNATURE:
DATE: 01/13/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/13/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/13/2025 01:12 PM - It Cannot Be Edited

Citations on this Visit Report are Under Appeal!


Created By: Leslie Ngo-Castaneda On 01/13/2025 at 12:06 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: HELIOTROPE ASSISTED LIVING
FACILITY NUMBER: 197610349

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/13/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87458(c)(1)(A)
Medical Assessment
(c) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the licensed medical professional's diagnosis or diagnoses and results of an examination for all of the following: (A) Communicable tuberculosis.

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 in 1 out of 1 TB test for R5 is missing which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/27/2025
Plan of Correction
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R5 needs TB test upon admission.
Under Appeal
Type B
Section Cited
CCR
87625(b)(3)
Managed Incontinence
(b) In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensee shall be responsible for the following: (3) Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence.

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 in 1 out of 1 urine smell could be smelled from the bedroom to the dining table. which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/27/2025
Plan of Correction
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Staff needs to be trained for incontinence cleanliness.
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:Nichelle Gillyard
LICENSING EVALUATOR NAME:Leslie Ngo-Castaneda
LICENSING EVALUATOR SIGNATURE:
DATE: 01/13/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/13/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/10/2026 12:52 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 02/06/2026 02:32 PM


Citations on this Visit Report are Under Appeal!


Created By: Leslie Ngo-Castaneda On 01/13/2025 at 12:34 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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: HELIOTROPE ASSISTED LIVING
FACILITY NUMBER: 197610349

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/13/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Under Appeal
Section Cited
Deficient Practice Statement
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This citation was deleted due to granted appeal on 9.24.2025.
POC Due Date:
Plan of Correction
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Type B
Section Cited
CCR
87465(c)(2)
Once ordered by the physician the medication is given according to the physician's directions.


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 in 1 out of 1 resident medication for bubble pack should be followed accordingly and not randomly which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/27/2025
Plan of Correction
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Licensee will need to train and advice staff regarding following sequence for rx. A letter will be sent to LPA regarding training.
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:Leslie Ngo-Castaneda
LICENSING EVALUATOR SIGNATURE:
DATE: 01/13/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/13/2025


LIC809 (FAS) - (06/04)
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