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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610436
Report Date: 03/03/2025
Date Signed: 03/03/2025 03:02:01 PM

Document Has Been Signed on 03/03/2025 03:02 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:DAY & NIGHT ASSISTED LIVINGFACILITY NUMBER:
197610436
ADMINISTRATOR/
DIRECTOR:		MERI MKRTUMYANFACILITY TYPE:
740
ADDRESS:17655 NORDHOFF STREETTELEPHONE:
(747) 344-3314
CITY:NORTHRIDGESTATE: CAZIP CODE:
91325
CAPACITY: 6CENSUS: 3DATE:
03/03/2025
TYPE OF VISIT:POCUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:30 PM
MET WITH:Karen Mesropyan, Designated AdministratorTIME VISIT/
INSPECTION COMPLETED:
03:20 PM
NARRATIVE
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On 03/03/25, at 12:30pm, Licensing Program Analyst (LPA) Gina Saucedo arrived at the facility to conduct an unannounced, Plan Of Correction (POC) and was greeted by Kyzylgul Almamatova, Caregiver. The purpose of the POC visit is to make sure deficiencies were corrected on reports issued on 12/11/2024. The designated administrator, Karen Mesropyan arrived about twenty (20) minutes later.

At 12:35 PM LPA toured the home and requested the following:

LPA reviewed all three (3) resident files and all three (3) staff files. All three (3) resident files were completed and POC’s were cleared-Admission Agreement, Pre Placement Appraisal, Resident Appraisal, Physician's Report and tuberculosis clearance and Needs and Appraisal. Two (2) out of three (3) files were completed. Staff # 2 (S2) is still missing health screening. LPA received the training required by staff and the CPR-Cardiopulmonary resuscitation for clearance of POC. An additional staff has been hired and has a completed file at the facility.

The medication, sharps, and chemicals were locked and inaccessible to residents-POC was cleared.
The garage door and where they keep the sharps was repaired-POC cleared.

Two (2) citations will be issued on 809-D for The Liability insurance Coverage that is required and S2 missing Health Screening.

An exit interview was conducted, citation(s) were issued, appeals rights and a copy of this report was given to the designated administrator.




SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Gina Saucedo
LICENSING EVALUATOR SIGNATURE: DATE: 03/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/03/2025
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 03/03/2025 03:02 PM - It Cannot Be Edited


Created By: Gina Saucedo On 03/03/2025 at 12:52 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: DAY & NIGHT ASSISTED LIVING
FACILITY NUMBER: 197610436

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/03/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/12/2025
Section Cited
HSC
1569.605

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HSC 1569.605 shall maintain liability insurance covering injury to residents and guests in the amount of at least one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000). This requirement is not met by:
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The licensee/administrator will send copy of liability insurance that is required to LPA by

POC Due Date: 03/12/25.
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Based on the record review, the licensee did not comply with the section cited above in one documentation not showing required liability insurance which poses an immediate health, safety or personal rights risk to persons in care.
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Type B
03/12/2025
Section Cited
CCR87412(a)(11)

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(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: (11) A health screening as specified in Section 87411...This requirement is not met as evidenced by:
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The health screening of S2 is to be sent to the LPA.

POC Due Date 03/12/25
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Based on the record review, the licensee did not comply with the section cited above in one out of three staff not having a health screening which poses/posed 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:Troy Agard
LICENSING EVALUATOR NAME:Gina Saucedo
LICENSING EVALUATOR SIGNATURE:
DATE: 03/03/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/03/2025


LIC809 (FAS) - (06/04)
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