195850293-4-9-2025-29-AS-TBYE-DFKUZ6-20250409160101

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 195850293
Report Date: 04/09/2025
Date Signed: 04/09/2025 04:01:37 PM

Document Has Been Signed on 04/09/2025 04:01 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:	NORTH RESIDENTIAL CARE INC		FACILITY NUMBER:	195850293
ADMINISTRATOR/ DIRECTOR:	DURGARYAN, REBEKA		FACILITY TYPE:	740
ADDRESS:	7846 AGNES AVE		TELEPHONE:	(818) 404-0290
CITY:	NORTH HOLLYWOOD	STATE: CA	ZIP CODE:	91605
CAPACITY: 6		CENSUS: 5	DATE:	04/09/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:32 AM
MET WITH:	Rebeka Durgaryan		TIME VISIT/ INSPECTION COMPLETED:	04:15 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	Licensing Program Analyst (LPA) Trevor Byrne arrived at the facility unannounced to conduct a required annual visit at 09:32 AM. LPA met with facility staff who contacted facility Administrator Rebeka Durgaryan via telephone call. The facility Administrator arrived to the facility at 09:52 AM. Entrance interview conducted and the reason for the visit was explained. Beginning at 09:53 AM, the LPA, along with facility Administrator 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: COMMON AREAS: This includes the living room, dining room, and hallways. LPA observed the living room to be clean and properly furnished at the time of the visit. The living room contains a couch, a television, an office area for the Administrator, a locked storage cabinet containing resident medication, and activities for resident use. The dining room was observed to be clean and contained adequate amounts of seating for resident use. LPA observed all required postings for the facility located on the living room wall. Fire extinguishers were observed throughout the facility, and all were fully charged and purchased on 02/11/2025. Fire alarms, fire doors, and carbon monoxide alarms were tested at 12:06 PM and functioned properly at the time of inspection. LPA observed cameras throughout the common areas of the facility. The Administrator confirmed that the cameras are not active and do not record audio. Continued on LIC 809C.

NAME OF LICENSING PROGRAM MANAGER: Kasandra Lopez
NAME OF LICENSING PROGRAM ANALYST: Trevor Byrne
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/09/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/09/2025

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 9

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 9

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: NORTH RESIDENTIAL CARE INC	FACILITY NUMBER: 195850293
	VISIT DATE: 04/09/2025

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

BEDROOMS: There are five (5) bedrooms in the facility; one (1) is a single occupancy room, two (2) are dual occupancy rooms, one (1) is a staff bedroom, and one (1) bedroom is unoccupied. LPA and facility Administrator toured all five (5) bedrooms. All resident rooms were observed to be furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting. Auditory alarms were observed on all facility exits and all were functioning at the time of inspection. The staff bedroom was observed to contain the facility’s emergency food and water supplies and was properly secured and inaccessible to clients in care.

BATHROOMS: There are three (3) bathrooms at the facility. Two (2) bathrooms are designated as shared resident bathrooms and one (1) is designated as a private resident bathroom. All bathrooms were observed to be clean and in good repair and all were equipped with nonskid surfaces. Two (2) bathrooms were observed to contain secured cabinets that contained cleaning supplies and grooming supplies. Grab bars were observed in all showers and near all toilets, all were properly secured. The water temperature was measured between 108.9 and 117.3 degrees Fahrenheit, which is within the range required by regulation.

KITCHEN/LAUNDRY: 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 lock box to contain knives. LPA observed the laundry to be located adjacent to the kitchen. LPA observed secured cabinets in the laundry to contain detergents and extra cleaning supplies.

OUTDOOR SPACE: The facility has one (1) emergency exit gate located in the back yard. All railings located at the facility were secured properly. LPA observed clear passageways for emergency exit use. The facility has adequate shaded seating outdoors for resident use.

Continued on LIC 809C.

NAME OF LICENSING PROGRAM MANAGER: Kasandra Lopez
NAME OF LICENSING PROGRAM ANALYST: Trevor Byrne
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/09/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/09/2025

LIC809 (FAS) - (06/04)

Page: 3 of 9

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: NORTH RESIDENTIAL CARE INC	FACILITY NUMBER: 195850293
	VISIT DATE: 04/09/2025

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

RECORD REVIEW: Record review began at 10:33 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, first aid certification, consent forms, and personal rights. Five (5) staff files were reviewed. All staff files contained the required documentation and trainings. Five (5) resident files were reviewed. One (1) resident was identified by their physician to be a bedridden resident. LPA spoke with the resident who confirmed that they were unable to reposition without staff assistance. LPA confirmed that the facility’s fire clearance does not permit them to admit bedridden residents. LPA informed the Administrator that admitting bedridden clients is a violation of their fire clearance and poses an immediate safety risk to clients in care. LPA informed the Administrator that this is a zero-tolerance violation and an immediate civil penalty in the amount of $500 will be assessed on today’s date (04/09/2025). The Administrator expressed understanding and confirmed that the resident would be relocated to a licensed facility that has an appropriate fire clearance to care for bedridden residents.

MEDICATION REVIEW: Medication review began at 12:38 PM. Medications are stored centrally and securely in a cabinet in the living room. Medications for three (3) residents were observed. All medications observed were documented appropriately on their centrally stored medication and destruction record sheets and their Medication Administration Record sheets. No deficiencies were observed during medication review.

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. Emergency disaster drills are conducted quarterly; the facility’s last emergency disaster drill was conducted on 01/30/2025. The facility’s emergency disaster plan is up to date and is adequate. Both the infection control plan and the emergency disaster plan were reviewed/updated annually by the facility’s Administrator.

INTERVIEWS: LPA interviewed one (1) staff and three (3) residents. All residents interviewed stated that the staff treat them well and are attentive to their needs. No residents interviewed had concerns with the facility. The staff member interviewed was knowledgeable on their role and responsibilities, resident rights, the different forms of abuse and the appropriate reporting procedures for suspected abuse.

Continued on LIC 809C.

NAME OF LICENSING PROGRAM MANAGER: Kasandra Lopez
NAME OF LICENSING PROGRAM ANALYST: Trevor Byrne
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/09/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/09/2025

LIC809 (FAS) - (06/04)

Page: 4 of 9

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: NORTH RESIDENTIAL CARE INC	FACILITY NUMBER: 195850293
	VISIT DATE: 04/09/2025

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	During today’s visit LPA obtained a copy of the facility’s LIC 500, resident roster, and liability insurance. Pursuant to Title 22 of the CA Code of Regulations, the following deficiency and civil penalty were cited (refer to LIC 809-D): Exit interview conducted and copy of the report was issued and appeal rights provided.

NAME OF LICENSING PROGRAM MANAGER: Kasandra Lopez
NAME OF LICENSING PROGRAM ANALYST: Trevor Byrne
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/09/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/09/2025

LIC809 (FAS) - (06/04)

Page: 5 of 9

Document Has Been Signed on 04/09/2025 04:01 PM - It Cannot Be Edited

Created By: Trevor Byrne On 04/09/2025 at 03:10 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. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: NORTH RESIDENTIAL CARE INC	FACILITY NUMBER: 195850293
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/09/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87202(a)(2)

Fire Clearance

(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal: (2) Bedridden persons This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, and record review, the licensee did not comply with the section cited above as the facility does not have a bedridden approved fire clearance and one resident was determined by their physician to be bedridden and confirmed that they were unable to reposition without assistance which poses an immediate safety risk to persons in care.
	POC Due Date: 04/10/2025
	Plan of Correction
1 2 3 4	Licensee agreed to relocate the identified resident to NoHo Residential Care which is another facility operated by the same Administrator and has a bedridden approved fire clearance. Administrator agreed to relocate the resident no later than 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.

	Kasandra Lopez
NAME OF LICENSING PROGRAM MANAGER:

	Trevor Byrne
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/09/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/09/2025

LIC809 (FAS) - (06/04)

Page: 6 of 9