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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195850262
Report Date: 12/15/2023
Date Signed: 12/15/2023 03:38:05 PM


Document Has Been Signed on 12/15/2023 03:38 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 12/15/2023 01:28 PM

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

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Licensing Program Analysts (LPAs) Emily Peraldi and Martha Arroyo conducted an unannounced visit for the purpose of checking the health and safety of four (4) residents residing at this location. At 10:55 a.m., the LPAs met with staff and explained the reason for the visit. At 11:49 a.m., the LPAs spoke with the Applicant, Pogos Tofalyan over the telephone. The Applicant was not available during the time of the visit and authorized staff to sign the report. This is an amended report from the previous report issued on 12/15/2023.
At 10:55 a.m., the LPAs gained access to the property. At 11:45 a.m., the LPAs conducted a brief physical plant tour. During the time of the visit, there were no new residents observed. During the telephonic conversation with the Applicant, Pogos T at 11:49 a.m., LPA Peraldi again spoke with him regarding obtaining more perishable and nonperishable food, facility telephone and staffing plan and schedule, facility application status/ progress and medication of residents. Pogos T. stated that grocery shopping will be conducted today on 12/15/2023 and will provide proof to the LPA.
During a Case Management visit conducted on 12/08/2023, LPAs Peraldi and Chochian issued and read the Notice of Operation in Violation of Law (NOVL) with Applicant. The LPAs also reminded the applicant that no new residents shall be admitted until the facility is licensed and failure to comply could affect approval of his license.
The LPAs spoke with staff and Applicant, Pogos T. with concerns at the facility that include:
- The amount of perishable and non-perishable food available to the residents.
- Staff schedules including coverage for caregivers and administrative staff.
- Self-administration of Medication to the residents.
- Application process.
The Department will continue to frequently monitor the health and safety of the four (4) residents. The Department is also in communication with WISE and Healthy Aging Long-Term Ombudsman Program (LTCO) regarding concerns at the facility. Exit interview conducted. A copy of the report was provided.
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Emily PeraldiTELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:
DATE: 12/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/15/2023
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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