<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610573
Report Date: 09/17/2025
Date Signed: 09/17/2025 12:23:21 PM

Document Has Been Signed on 09/17/2025 12:23 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:HASKELL HOUSEFACILITY NUMBER:
197610573
ADMINISTRATOR/
DIRECTOR:		VANOYAN, ERNAFACILITY TYPE:
740
ADDRESS:11422 HASKELL AVE.TELEPHONE:
(640) 900-0099
CITY:GRANADA HILLSSTATE: CAZIP CODE:
91344
CAPACITY: 6CENSUS: 4DATE:
09/17/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:10 AM
MET WITH:Marine Navruzyan, LicenseeTIME VISIT/
INSPECTION COMPLETED:
12:10 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 09/17/2025 at 8:10 AM, Licensing Program Analyst (LPA) Gina Saucedo and conducted an unannounced, Annual Inspection and met with Caregiver, Rosa Flores. Licensee was called and arrived about thirty (30) minutes, Marine Navruzyan, Licensee after and was advised of visit.

LPA asked for the census, staff and resident files.

The physical plant was toured inside and out at 9:55am.

Living/Dining Room Area: LPA observed the living room furniture to be clean and in good repair. The facility maintains a comfortable temperature at 75 degrees Fahrenheit with a large television. There is enough seating for all residents to sit and eat.

KITCHEN: The facility has a kitchen area that is equipped with a refrigerator, stove, microwave oven and sink. There is an adequate supply of nonperishable food and dining ware to accommodate a maximum capacity of six (6). Knives were observed locked in a kitchen drawer on your left hand side. The medication is also kept in the kitchen on one (1) of the top drawers locked and inaccessible to the residents.



BEDROOMS: There are six (6) bedrooms. Five (5) are designated for resident use. One (1) bedroom is reserved for staff. Bedroom #1 is a shared room. The other rooms are private, resident rooms. The bedrooms with have proper bedding, night stands/dressers, televisions, and linen. The bedrooms have sufficient lighting and closet space.

LIC809C-continued
NAME OF LICENSING PROGRAM MANAGER: Troy Agard
NAME OF LICENSING PROGRAM ANALYST: Gina Saucedo
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/17/2025
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 3
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)
Page: 2 of 3
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: HASKELL HOUSE
FACILITY NUMBER: 197610573
VISIT DATE: 09/17/2025
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
BATHROOMS: The facility has three (3) bathrooms. Two (2) of the bathrooms are private used with it's own shower. The other bathroom is located in the hallway. All three (3) bathrooms were observed to have the proper fixtures, grab bars, and non-skid mats. The hot water delivered in the bathrooms measured between 107 and 108 degrees.

There is no laundry room. The washer and dryer are located in the kitchen. Detergents and cleaning supplies are kept separately in a locked closet down the hallway.



MEDICATIONS: The medications and medication records will be kept in a locked cabinet in the kitchen.

OFFICE/STAFF BEDROOM: Staff office is located by the front entrance. Resident and personnel files will be maintained in a locked filing cabinet there. The staff bedroom is located by the dining room.

ADMINISTRATION: The Liability Insurance was reviewed and will be renewed on 02/06/2026. There are several Personal Rights, Ombudsman, Resident Council, Theft and Loss, Family Council, Disaster and Fire Drill was last conducted August 01, 2025.

There is also a signal system in the facility. There is one (1) fire extinguisher fully charged and dated July-2025. The carbon monoxide and the smoke detector were tested, and they were operable, interconnected.


GARAGE: The garage is not attached to the home. It is located at the backyard. The garage is used for extra storage. There is a pool that is locked and inaccessible to the residents. There is a fence surrounded around the pool.

An exit interview was conducted, no citation(s) were issued, and a copy of this report was given to the Licensee.
NAME OF LICENSING PROGRAM MANAGER: Troy Agard
NAME OF LICENSING PROGRAM ANALYST: Gina Saucedo
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2025
LIC809 (FAS) - (06/04)
Page: 3 of 3