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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610426
Report Date: 09/24/2025
Date Signed: 09/24/2025 03:09:11 PM

Document Has Been Signed on 09/24/2025 03:09 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:MK QUALITY CARE ASSISTED LIVINGFACILITY NUMBER:
197610426
ADMINISTRATOR/
DIRECTOR:		MARYAM HARUTYUNYANFACILITY TYPE:
740
ADDRESS:18960 KESWICK STREETTELEPHONE:
(818) 648-0011
CITY:RESEDASTATE: CAZIP CODE:
91335
CAPACITY: 6CENSUS: 6DATE:
09/24/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:45 PM
MET WITH:Maryam Harutyunyan, AdministratorTIME VISIT/
INSPECTION COMPLETED:
03:35 PM
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At 12:45 PM, Licensing Program Analyst (LPA) Huma Rahimi, conducted an unannounced annual inspection at the facility mentioned above. LPA met with staff Hasmik Boyajyan and the Administrator Maryam Harutyunyan was contacted via telephone. LPA explained the reason for the visit. The Administrator arrived shortly after. Physical tour was conducted with the Administrator and LPA observed the following:

KITCHEN: The facility has a Kitchen area that is equipped with a refrigerator, microwave oven and sink. There were adequate supplies of perishable and nonperishable food and dining ware to accommodate a maximum capacity of six (6). Knives were observed locked in a lock box.



MEDICATIONS: LPA observed the medication locked and inaccessible to residents in care in a cabinet in the living room; There was a complete first aid kit available in the medication cabinet. LPA observed medications (XYZAL Allergy, Nystatin Triamcinolone Acetonide) unlocked and accessible to residents in care in bedrooms #5 and #1.

SAFETY: The smoke alarms and carbon monoxide detector are battery operated. The facility has one new fire extinguisher that was purchased on 01/13/2025.

BEDROOMS: There are six (6) bedrooms designated for client use. All six (6) bedrooms are private. Bedroom number one (1) is cleared for bedridden. All other rooms are cleared for non-ambulatory. All bedrooms are furnished with beds, night stand, chairs, dresser, bedding and linen. The bedrooms have sufficient lighting and closet space.
Continue on LIC 809C
NAME OF LICENSING PROGRAM MANAGER: Nichelle Gillyard
NAME OF LICENSING PROGRAM ANALYST: Huma Rahimi
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/24/2025
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 S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: MK QUALITY CARE ASSISTED LIVING
FACILITY NUMBER: 197610426
VISIT DATE: 09/24/2025
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BATHROOMS: The facility has four (4) bathrooms. Room three and four have a shared/common bathroom. The bathrooms were observed to have the proper fixtures, grab bars, and non-skid mats. The hot water delivered in the bathrooms measured between 108.0 degrees. One of the bathrooms is designated for staff use and LPA observed to be unlocked and accessible to residents in care with disinfecting wipes.

COMMON AREAS: These included the TV and activity room which were equipped with living room furniture, a television, tables and chairs. There is a fireplace with a screen and a glass slide. It is non-operational. No fireplace tools or fixtures present. The dining area has a large dining room table to accommodate six (6). There were no visible immediate hazards.

LAUNDRY ROOM: The laundry room is located in the in the hall beside room # 6. It was observed with two locked doors to make it inaccessible to the residents.

OFFICE/STAFF WORKSTATION: Staff workstation is located at the end of the hallway by bedroom #5.

SURROUNDING GROUNDS: The driveway, passageways and entrance to the home was clear of obstruction. All entry and exit doors have a functional auditory alert when the doors open. The front yard of the facility has a patio and outdoor furniture to accommodate the six (6) residents. The facility front yard has sufficient yard space. There is a closed jacuzzi that is fenced all around with a gate and was observed to locked and inaccessible to residents in care. The fence surrounding the jacuzzi is approximately 5 feet high all around its parameters. You will need a key to unlock the padlock to gain entry to the jacuzzi as it is kept locked at all times.

Between 1:20 PM to 3:00 PM, LPA reviewed records of six (6) residents and two (2) staff. Residents and staff records appeared to be complete and updated. LPA reviewed R1's Physician report, and per R1's Physician, R1 is unable to inject or administrator his/her medication; however, the facility staff allowed R1 to inject him/herself for his/her diabetes.
Administrative: LPA collected Certificate of Liability Insurance, and LIC500.

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: Huma Rahimi
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/24/2025 03:09 PM - It Cannot Be Edited


Created By: Huma Rahimi On 09/24/2025 at 02:20 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: MK QUALITY CARE ASSISTED LIVING
FACILITY NUMBER: 197610426

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/24/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(f)(2)
Care of Persons with Dementia (f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.

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 leaving over the counter and prescribed medications in bedroom #1 & #5, and disinfecting wipes in the staff bathroom, unlocked and accessible to residents in care, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/26/2025
Plan of Correction
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Administrator agreed to conduct an in-service training to all staff regarding the care for Dementia residents and always keep medications and disinfecting wipes locked. Proof of training will be emailed to LPA by POC date.
Type A
Section Cited
CCR
87629(b)(1)
(b) In addition to Section 87611...retain residents who require injections shall be responsible for the following: (1) Ensuring that injections are administered by an appropriately skilled professional should the resident require assistance.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review and interview, licensee failed to ensure R1 who is unable to administer injections by self, per physician's report and had injections administered by R1 not by an appropriate skilled professional, which poses an immediate health and safety risk to residents in care.
POC Due Date: 09/26/2025
Plan of Correction
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Administrator will submit a written plan on how this deficiency will be corrected by POC due date 09/26/2025.
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:
Huma Rahimi
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/24/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/24/2025


LIC809 (FAS) - (06/04)
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