195850143-5-30-2025-29-AS-QHUH-DH3SYP-20250527141752

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 195850143
Report Date: 05/27/2025
Date Signed: 05/30/2025 01:01:46 PM

Document Has Been Signed on 05/30/2025 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 N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	A COMPASSION VALLEY		FACILITY NUMBER:	195850143
ADMINISTRATOR/ DIRECTOR:	KUYUMCHYAN, BREANNA		FACILITY TYPE:	740
ADDRESS:	7460 MAMMOTH AVE.		TELEPHONE:	(818) 983-9165
CITY:	VAN NUYS	STATE: CA	ZIP CODE:	91405
CAPACITY: 6		CENSUS: 0	DATE:	05/27/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	12:51 PM
MET WITH:	Junie Shakhvaladyan - Applicant		TIME VISIT/ INSPECTION COMPLETED:	02:30 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	This report is being amended, due to the Licensee representative being unavailable during the time of visit. Licensing Program Analyst (LPA) Quoc Huynh arrived at the facility unannounced to conduct a required annual visit at 12:33PM. The LPA was greeted by Staff Mary Jane Bernardo, informed them of the reason for the visit, and Staff notified the Applicant. Applicant Junie Shakhvaladyan arrived at 1:25PM. Entrance interview conducted. Staff notified LPA that the facility is undergoing a change of ownership, and the proposed facility name is Maddie’s Green Haven Facility. Residents and Staff from A Compassion Valley are no longer associated with the facility and have been relocated prior to the change of ownership. Beginning at 12:51PM, the LPA and the Staff toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The following was observed: KITCHEN: Knives are stored inaccessible in a locked drawer. Cleaning supplies were stored inaccessible and locked under the sink. Kitchen appliances were clean and in operable condition. The facility has a sufficient supply of perishable and non-perishable food. Food in the refrigerator and freezer were observed to be of good quality. One fire extinguisher was observed in the kitchen. Report Continued on LIC 809-C

NAME OF LICENSING PROGRAM MANAGER: Kristin Heffernan
NAME OF LICENSING PROGRAM ANALYST: Quoc Huynh
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/27/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/27/2025

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 05/30/2025 01:02 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 05/30/2025 12:57 PM

Created By: Quoc Huynh On 05/27/2025 at 02:06 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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: A COMPASSION VALLEY	FACILITY NUMBER: 195850143
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/27/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(e)(2)

Maintenance and Operation

(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in 1 out of 1 sinks delivering hot water measured 122 degrees F which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/02/2025
	Plan of Correction
1 2 3 4	Licensee representative will make a visit to the facility to adjust the water temperature. Licensee representative will send CCLD photo proof of the adjusted water temperature in the hallway bathroom by POC due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Kristin Heffernan
NAME OF LICENSING PROGRAM MANAGER:

	Quoc Huynh
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/27/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/27/2025

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 N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: A COMPASSION VALLEY	FACILITY NUMBER: 195850143
	VISIT DATE: 05/27/2025

NARRATIVE

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GARAGE: The garage is attached to the kitchen and contains extra food in refrigerators and freezers, emergency food and water, general storage, and laundry machines. Laundry machines were in good condition and were observed to be operational. One fire extinguisher was observed in the garage.

COMMON AREAS: At the time of the visit, living room and dining room furniture was observed to be in good condition. The facility maintained a comfortable temperature throughout the visit. Smoke and carbon monoxide detectors were last tested in March of 2025 and were operational.

BEDROOMS/RESTROOMS: There were four (4) total bedrooms that were observed to be furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. Extra linens are stored in the hallway cabinets. There were three (3) total restrooms in the facility: one (1) shared restroom located in the hallway and two (2) private resident restrooms. Restrooms were clean and sanitary and in operating condition with grab bars and non-slip surfaces. All restrooms were sufficiently stocked with soap, paper products, and displayed hand washing signs. Hot water was tested and measured at 122 degrees F.

OUTDOOR AREA: The backyard has two covered patio areas equipped with furniture for resident and visitor use. There was two self-latching side gates for emergency use that lead to the front yard. The front yard has a driveway with a remote gate and a door that remains locked for everyday visitors. No bodies of water noted, and exits are free of obstructions. There were two locked sheds that were observed to be empty and will be used for storage.

LPA spoke with the Licensee Representative Eva Elizalde on 05/30/2025 at 12:16PM via telephone call. Eva understood that the LPA will send the report via email and will need signatures by the end of business day.

Persuant to CA Title 22 Regulations, the following deficiency was cited (Refer to LIC 809-D). Exit interview conducted. A copy of today's report and appeal right were reviewed and provided.

NAME OF LICENSING PROGRAM MANAGER: Kristin Heffernan
NAME OF LICENSING PROGRAM ANALYST: Quoc Huynh
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/27/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/27/2025

LIC809 (FAS) - (06/04)

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