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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610571
Report Date: 08/20/2025
Date Signed: 08/20/2025 01:01:50 PM

Document Has Been Signed on 08/20/2025 01:01 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:KLN BOARDING CAREFACILITY NUMBER:
197610571
ADMINISTRATOR/
DIRECTOR:		KATHERINE NAGAPETYANFACILITY TYPE:
740
ADDRESS:8706 HERRICK AVENUETELEPHONE:
(818) 406-3301
CITY:SUN VALLEYSTATE: CAZIP CODE:
91352
CAPACITY: 6CENSUS: 6DATE:
08/20/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Katherine NagapetyanTIME VISIT/
INSPECTION COMPLETED:
01:15 PM
NARRATIVE
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At approximately 9:30 a.m. on 08/20/25 Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced complaint visit. LPA met with staff and later the administrator and disclosed the reason for the visit.

The facility was last visited on 07/02/2024 for a prelicensing inspection. It is a single story building with four (04) bedrooms, two (02) bathrooms, kitchen, garage, laundry room, common areas, outdoor space, and a pool. It has an approved fire clearance for six (06) residents, of which five (05) can be non-ambulatory and one (01) bedridden resident in bedroom #1. Approved hospice waivers for (06) residents.

LPA entered through an unlocked door with a keypad. At the main entrance, LPA observed postings including but not limited to the facility’s nondiscrimination notice, theft and loss policy, personal rights, rights of resident councils, emergency disaster plan, and contacts for the Ombudsman and confidential complaints. At approximately 9:45 a.m. LPA measured the room temperature to be 77 degrees Fahrenheit. Cameras were observed on the exterior of the facility. Walls, floors, windows, screens, and blinds were clean and in good repair. The living room contained furniture in good repair, an appropriately covered fireplace, and reading materials. Puzzles, art supplies, and exercise equipment were stored in a hallway closet.

The facility had four (04) bedrooms. All bedrooms contained a nightstand, storage, and a bed with adequate bedding. All furnishings were clean and in good condition. At approximately 10:10 a.m. LPA observed the resident in Bedroom #2 with full bed rails. Interview with the administrator at approximately 10:45 a.m. revealed the resident is not receiving hospice services. A deficiency is issued on the corresponding LIC 809-D page for the retaining a resident with full bed rails without hospice services.

NAME OF LICENSING PROGRAM MANAGER: Naira Margaryan
NAME OF LICENSING PROGRAM ANALYST: Nicholas Reed
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 08/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/20/2025
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 08/20/2025 01:01 PM - It Cannot Be Edited


Created By: Nicholas Reed On 08/20/2025 at 12:36 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: KLN BOARDING CARE
FACILITY NUMBER: 197610571

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/20/2025

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 in two (02) out of two (02) staff with incomplete files which poses/posed a potential health, safety or personal rights risk to persons in care
POC Due Date: 08/30/2025
Plan of Correction
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Licensee to obtain health screening, criminal record statement, personnel record, and CPR certification, acquire necessary signatures, and maintain complete records for all staff. Licensee will submit proof of correction by the POC due date.
Type B
Section Cited
CCR
87506(b)
Resident Records
(b) Each resident's record shall contain at least 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 in six (06) out of six (06) residents with incomplete files which poses/posed a potential health, safety or personal rights risk to persons in care
POC Due Date: 08/30/2025
Plan of Correction
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Licensee to provide residents with consent forms, personal rights forms, and all other missing files, acquire necessary signatures, and maintain complete records for all residents. Licensee will submit proof of correction by the POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Naira Margaryan
NAME OF LICENSING PROGRAM MANAGER:
Nicholas Reed
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/20/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/20/2025


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.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: KLN BOARDING CARE
FACILITY NUMBER: 197610571
VISIT DATE: 08/20/2025
NARRATIVE
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LPA observed an adequate supply of perishable and non-perishable foods in the kitchen refrigerator, freezer, and pantry. The garage was locked and inaccessible. At 10:25 a.m. LPA measured the refrigerator and freezer temperatures to be 40 and -3 degrees Fahrenheit, respectively. The stove hood and surface were clean. Appliances were in good condition. Sharps were locked under a counter. Medications were locked above the counter in a cabinet. Cleaning solutions were locked in the laundry area along with a fully-stocked first aid kit and a washing machine and dryer. At approximately 10:30 a.m. LPA observed a fully charged fire extinguisher in the kitchen. All emergency exit paths were free from obstructions. The exit gate was unlocked with a self-closing latch. At approximately 10:40 a.m. the dual-purpose smoke and carbon monoxide detector was tested and operational. Facility detectors are hard-wired and functioned simultaneously during the test. The fire door near the main entrance closed during the test as well. Three (03) out of three (03) auditory alarms were tested and functioning. The house telephone was called at 11:00 a.m. and deemed operational.

The facility had two (02) bathrooms. Bathrooms contained liquid soap, paper towels, a trash can with a tight fitting lid, grab bars in the shower, and a non-skid mat in the shower. The toilet in Bathroom #1 did not have grab bars. A deficiency is issued on the corresponding LIC 809-D page for the lack of grab bars. At 12:40 p.m. LPA measured the water temperature in Bathroom #1 to be 114.0 degrees Fahrenheit.

LPA observed a covered patio area in the rear of the facility. The patio contained furniture in good condition and exercise equipment. The ramp which led out was secure. The pool was gated and locked to be inaccessible. A storage shed was locked and contained decorations.

Around 11:30 a.m. LPA reviewed resident and personnel files. All resident and staff files were available but incomplete. Deficiencies are issued on the corresponding LIC 809-D for incomplete staff and resident files.

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

NAME OF LICENSING PROGRAM MANAGER: Naira Margaryan
NAME OF LICENSING PROGRAM ANALYST: Nicholas Reed
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/20/2025 01:01 PM - It Cannot Be Edited


Created By: Nicholas Reed On 08/20/2025 at 12:47 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: KLN BOARDING CARE
FACILITY NUMBER: 197610571

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/20/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(e)(4)
87303 Maintenance and Operation (e) Water supplies and plumbing fixtures shall be maintained as follows:
(4) Grab bars shall be maintained for each toilet; bathtub and shower used by residents.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above in one (01) out of two (02) toilets not having grab bars which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/30/2025
Plan of Correction
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Licensee to acquire grab bars through a commode or new installation and provide a photograph of the correction by the 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.
Naira Margaryan
NAME OF LICENSING PROGRAM MANAGER:
Nicholas Reed
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/20/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/20/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/20/2025 01:01 PM - It Cannot Be Edited


Created By: Nicholas Reed On 08/20/2025 at 12:50 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: KLN BOARDING CARE
FACILITY NUMBER: 197610571

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/20/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87608(a)(5)(B)
87608 Postural Supports (a) Based on the individual's preadmission appraisal... Postural supports may be used under the following conditions. (5) Under no circumstances shall postural supports include tying, depriving, or limiting the use of a resident's hands or feet. (B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above in one (01) out of six (06) residents using full bed rails without a prescription or hospice services which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/21/2025
Plan of Correction
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Licensee to discuss the issue with the resident's family and determine whether half bed rails will be used or to assist the resident in obatining hospice services. Licensee to remove the full bed rails in the meantime.
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.
Naira Margaryan
NAME OF LICENSING PROGRAM MANAGER:
Nicholas Reed
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/20/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/20/2025


LIC809 (FAS) - (06/04)
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