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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610581
Report Date: 05/12/2025
Date Signed: 05/12/2025 03:18:56 PM

Document Has Been Signed on 05/12/2025 03:18 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:COVELLO HOMESFACILITY NUMBER:
197610581
ADMINISTRATOR/
DIRECTOR:		VARDAN BAGHDASARYANFACILITY TYPE:
740
ADDRESS:18807 COVELLO STREETTELEPHONE:
(818) 279-1415
CITY:RESEDASTATE: CAZIP CODE:
91335
CAPACITY: 6CENSUS: 4DATE:
05/12/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:45 AM
MET WITH:Vardan Baghdasaryan, AdministratorTIME VISIT/
INSPECTION COMPLETED:
03:45 PM
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At 9:45 AM, Licensing Program Analyst (LPA) Huma Rahimi conducted an unannounced Annual Inspection visit to the above facility and met with the staff Ronald Lasam. The staff contacted the Administrator Vardan Baghdasaryan via telephone and LPA explained the reason for the visit. The Administrator arrived at the facility at 10:15 AM.

The facility is a single-story building. LPA conducted a physical plant tour of the facility inside and outside and observed the following:

KITCHEN: At 10:20 AM, LPA toured the kitchen. The kitchen area is equipped with a refrigerator, microwave oven, sink. Stove was observed in a good working condition. LPA observed adequate supplies of perishable and nonperishable food. LPA observed a knife and a scissor in the dash rack, and two other knives in the kitchen cabinet accessible to residents in care. Furthermore, LPA observed a Lysol disinfectant spray on the top of the medication cabinet which is placed next to the kitchen and LPA also observed vitamins and supplementals in one of the kitchen cabinets unlocked and accessible to residents in care.LPA also observed other chemicals and toxins and were locked under the sink and inaccessible to residents.

BEDROOMS: At 10:25 AM, LPA observed that the facility has six (6) bedrooms of which five (5) bedrooms are for resident’s use and one (1) designated for staff which is locked and inaccessible to resident. Bedroom # two (2), and bedroom # three (3) are currently vacant. In bedroom #5 LPA observed medication of Resident #2 (R2) accessible and unlocked to residents in care. LPA observed all bedrooms properly furnished with beds, dressers and required bedding, chest drawer, and linen. The bedrooms have sufficient closet space and have sufficient lighting. Facility have a live-in and an awake staff.


Continue on LIC 809C
NAME OF LICENSING PROGRAM MANAGER: Nichelle Gillyard
NAME OF LICENSING PROGRAM ANALYST: Huma Rahimi
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/12/2025
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: COVELLO HOMES
FACILITY NUMBER: 197610581
VISIT DATE: 05/12/2025
NARRATIVE
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Between 11:40 AM to 1:15 PM, LPA reviewed records of four (4) residents and three (3) staff. Residents and staff records appeared to be complete and updated.

Administrative: LPA collected Certificate of Liability Insurance, and LIC500.

Deficiencies were issued today’s visit. Appeal right explained.

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: 05/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2025
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: COVELLO HOMES
FACILITY NUMBER: 197610581
VISIT DATE: 05/12/2025
NARRATIVE
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Bathrooms: The facility has three (3) bathrooms. All bathrooms contained fully stocked soap, paper towels, trash can, non-skid mats, and grab bars. LPA observed trash cans with tight fitting lids, Hot water temperature measured at 118.4°F. In two (2) out of three (3) bathrooms LPA observed disinfectant wipes accessible to residents in care.

Common Areas: The facility maintains a comfortable temperature at 71°F. The living room and dining area appeared clean and were properly furnished. The living room has a television, comfortable furniture. No obstructions and or tripping hazards throughout the facility.

Smoke detectors/carbon monoxide. Smoke detectors were located throughout the facility and are hard-wired. At 11:30 AM they were tested and observed to be operational. Carbon monoxide was located in a hallway and was also tested and observed to be operational.

Outside space: LPA observed a covered area with with furniture in good repair. All outdoor spaces and paths were free from obstructions. The exit door was observed with inward latch that can be easily opened and accessible.

Garage: LPA observed a garage with adequate incontinence supplies and with a working washing machine and dryer. LPA observed that garage was unlocked and all the laundry detergents and Colorax Beach were accessible to residents in care.

Medication: LPA observed that medication are kept in a cabinet next to the kitchen and was locked and inaccessible to residents in care. During review of R3's random medication revealed that the facility was supposed to start Atorvastatin (High Cholesterol Medication) a new bottle on 05/03/2025. During today's visit LPA counted R3's medication and it was discovered that there was a discrepancy and ten (10) extra pills were in the bottle. LPA asked the Administrator and the staff for explaining and both staff could not provide sufficient information as to why there were extra pills. LPA also observed Centrally Stored Medication (LIC 622) records and did not observe a current/updated medication record with all the required information. There was a complete first aid kit located in the medical supply cabinet by the dinning area.

Continue on LIC 809C

NAME OF LICENSING PROGRAM MANAGER: Nichelle Gillyard
NAME OF LICENSING PROGRAM ANALYST: Huma Rahimi
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/12/2025 03:18 PM - It Cannot Be Edited


Created By: Huma Rahimi On 05/12/2025 at 01:27 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: COVELLO HOMES
FACILITY NUMBER: 197610581

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/12/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(f)(2)
87705 - Care of Persons with Dementia(f) The following shall be stored inaccessible to residents with dementia: (f) The following shall be stored inaccessible to residents 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 in leaving R2 medication, other vitamins, cleaning supplies, and sharps unlocked and accessible to residents in care which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/13/2025
Plan of Correction
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Administrator locked medication and removed from the R2's room and the vitamins from the kitchen cabinet. Administrator locked the clieaning supplies and sharps away. Administrator agreed to conduct in-service training to all staff and submit a a proof upon completion to LPA by the POC due date.
Type A
Section Cited
CCR
87465(c)(2)
87465- Incidental Medical and Dental Care: c) If the resident's physician has stated in writing... 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 (observation) (interview) (record review)], the licensee did not comply with the section cited above in
not assuring that R3's prescribed medications were given as prescribed, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/13/2025
Plan of Correction
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Administrator agreed to schedule vendorized training for all staff including the Administrator and submit to CCL the vendor information and scheduled date of training. Training certifications to be submitted to CCL upon completion. Administrator also agreed to notify doctor and submit LIC 624 to CCL regarding the incident.
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: 05/12/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/12/2025


LIC809 (FAS) - (06/04)
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