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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195850290
Report Date: 11/19/2024
Date Signed: 11/19/2024 02:38:39 PM

Document Has Been Signed on 11/19/2024 02:38 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:MATEVOSIAN HOMEFACILITY NUMBER:
195850290
ADMINISTRATOR/
DIRECTOR:		MATEVOSIAN, RAFAELFACILITY TYPE:
735
ADDRESS:7500 BELLINGHAM AVETELEPHONE:
(818) 522-2222
CITY:NORTH HOLLYWOODSTATE: CAZIP CODE:
91605
CAPACITY: 4CENSUS: 4DATE:
11/19/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:43 AM
MET WITH:Lusine AsatryanTIME VISIT/
INSPECTION COMPLETED:
02:45 PM
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Licensing Program Analyst (LPA) Trevor Byrne arrived at the facility unannounced to conduct a required annual visit at 09:43 AM. LPA contacted facility Administrator Rafael Matevosian via telephone call. Facility staff member Lusine Asatryan (S1) arrived to the facility at 09:54 AM. Entrance interview conducted and the reason for the visit was explained.

Beginning at 09:55 AM, the LPA, along with S1 toured the physical plant areas inside and outside to ensure there are no health and safety hazards and that facility is in compliance with Title 22 Regulations. The following was observed:

OUTDOOR SPACE: The facility has one (1) emergency exit gate, LPA observed clear passageways for emergency exit use. The facility has adequate shaded outdoor seating for resident use. LPA observed three (3) appropriately secured sheds to contain tools, chemicals, paints, and other household supplies.

KITCHEN: The LPA observed the kitchen area to be clean. Kitchen appliances were in operable condition. The facility has a sufficient supply of two (2) days perishable and seven (7) days non-perishable food. LPA observed a secured drawer to contain knives and other sharp objects. The LPA observed a fire extinguisher to be fully charged and purchased on 03/09/2024.

BATHROOMS: There are three (3) bathrooms at the facility. Two (2) are designated as common resident bathrooms and one (1) is designated as a staff bathroom. All bathrooms were observed to be clean and in good repair and were equipped with nonskid surfaces. The water temperature was measured in all bathrooms between 106.2 degrees Fahrenheit and 110.7 degrees Fahrenheit which is in compliance with regulation.

Continued on LIC 809C.

SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Trevor Byrne
LICENSING EVALUATOR SIGNATURE: DATE: 11/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/19/2024
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
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: MATEVOSIAN HOME
FACILITY NUMBER: 195850290
VISIT DATE: 11/19/2024
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BEDROOMS: There are five (5) bedrooms in the facility; four (4) are designated for resident use and one (1) is designated as a staff room. All four (4) resident bedrooms are private rooms. LPA and S1 toured all four (4) resident rooms. All resident rooms were observed to be furnished appropriately with clean linens, appropriate furnishings, emergency flashlights, and sufficient lighting. The staff room was observed to be locked and inaccessible to clients in care.

COMMON AREAS: This includes the living room, dining room, storage room, and hallway. LPA observed the living room to be clean and properly furnished at the time of the visit. LPA observed the living room to contain a couch, television, an appropriately screened fireplace, and activities for resident use. The dining room was observed to be clean and contains adequate seating for resident use. The hallway was observed to contain two (2) properly secured closets and one (1) unsecured closet. One (1) secured closet contained resident files and medications. One (1) secured closet contained the facility’s cleaning supplies and an additional freezer. The unsecured closet contained the facility’s washer and dryer and adequate emergency food and water supplies. The storage room was observed to contain a pool table, lounge chair, and decorations. Smoke detectors and carbon monoxide detectors were tested at 10:31 AM and were functional at the time of the visit.

RECORD REVIEW: Record review began at 10:43 AM. Staff and resident records were reviewed for documents including, but not limited to: health screening, TB test, staff training records, fingerprint clearance, resident physician's report, needs and service appraisal, consent forms, and personal rights. Six (6) staff files were reviewed. All staff files contained the required documents and trainings. Four (4) resident files were reviewed. All resident files contained all required documentation and signatures. No deficiencies were observed during record review.

MEDICATION REVIEW / CASH RESOURCE REVIEW: Medication review began at 12:22 PM. Medications are stored centrally and securely in a locked closet in the hallway. Medications for two (2) residents were observed. All medications reviewed were documented properly on their centrally stored medication and destruction record sheet. No deficiencies were observed during medication review. This facility does not handle cash resources for clients, no audit was conducted.

Continued on LIC 809C.
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Trevor Byrne
LICENSING EVALUATOR SIGNATURE:

DATE: 11/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2024
LIC809 (FAS) - (06/04)
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 N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: MATEVOSIAN HOME
FACILITY NUMBER: 195850290
VISIT DATE: 11/19/2024
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INFECTION CONTROL / EMERGENCY DISASTER PLANNING: During today’s visit, the LPA reviewed the
facility's infection control practices and the facility's emergency disaster plan. The facility’s policies and procedures as it pertains to infection control are adequate. Last emergency disaster drill was conducted 09/21/2024. The facility’s emergency disaster plan and infection control plan are reviewed/updated by the facility administrator annually.

INTERVIEWS: LPA interviewed one (1) staff member. The staff member interviewed was knowledgeable on their role and responsibilities, the resident’s rights, the forms of abuse, and the appropriate reporting procedures for suspected abuse. LPA was unable to conduct client interviews during the inspection as all clients were out of the facility at the time the inspection was conducted.



During today’s visit LPA obtained a copy of the facility’s updated LIC500, resident roster, and liability insurance.

No deficiencies were observed during today’s inspection. Facility Administrator Rafael Matevosian was unable to sign this report but has designated facility Staff member Lusine Asatryan to sign on their behalf. Exit interview conducted and copy of the report was issued.

SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Trevor Byrne
LICENSING EVALUATOR SIGNATURE:

DATE: 11/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2024
LIC809 (FAS) - (06/04)
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