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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195850340
Report Date: 05/10/2023
Date Signed: 05/10/2023 01:30:28 PM

Document Has Been Signed on 05/10/2023 01:30 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 NORTH, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:HARMONY WELLNESS & CAREFACILITY NUMBER:
195850340
ADMINISTRATOR:ZARGERY,ZOHRABFACILITY TYPE:
735
ADDRESS:14632 COHASSET STREETTELEPHONE:
(818) 640-3369
CITY:VAN NUYSSTATE: CAZIP CODE:
91405
CAPACITY: 4CENSUS: 0DATE:
05/10/2023
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
08:40 AM
MET WITH:Zohrab Zargery, ApplicantTIME COMPLETED:
01:35 PM
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Licensing Program Analyst (LPA) Christine Yee conducted an announced Pre-licensing Visit to verify that the home meets Title 22 requirements. The Pre-licensing visit using the CARE tool was conducted with Zohrab Zargery, Applicant.

The home is a single storey family home consisting of a living room, a dining room, a kitchen, 4 bedrooms, 2 full bathrooms and a attached garage. The home is fire cleared for 1 AMBULATORY and 3 NON-AMBULATORY clients. Bedrooms #2, #3 and #4 are approved for Non-ambulatory clients.
The following was observed on today's visit:
  • the living room has a long sofa and a coffee table
  • the dining room has a long table with 6 chairs
  • the kitchen has a working stove and refrigerator. Located in the kitchen are 2 locked filing cabinets that will be used to store medications and facility files. Knives will be stored in a locked drawer
  • the laundry room has a washer and dryer. Cabinets in the laundry room will be used to store detergents and cleaning supplies
  • the back bathroom adjacent to the laundry room is designated for staff use
  • the 4 resident bedrooms all contain a queen size bed, a chair, dresser, lamp, closet and a night stand.
  • The beds were observed with a mattress cover, fitted sheet, flat sheet and comforter
  • a bath towel and a hand towel were observed in the hamper
  • all the facility windows have window blinds. No window bars were observed.
  • First aid kit , scissors and first aid manual was observed
  • The only fire extinguisher was observed in the kitchen
SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Christine Yee
LICENSING EVALUATOR SIGNATURE: DATE: 05/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/10/2023
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 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS NORTH, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: HARMONY WELLNESS & CARE
FACILITY NUMBER: 195850340
VISIT DATE: 05/10/2023
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  • The common bathroom was observed equipped with a grab bar and a non-skid mat
  • The water temperature was tested and it read 133.20 degrees Fahrenheit
  • the interconnected smoke and carbon monoxide detectors were tested and were operational. The 2 carbon monoxide detectors are located in the hallway by the front door and the residents rooms,.
  • The back yard has a covered patio with a table and chairs
  • The trash cans were tightly sealed.

The following corrections need to be made:
  • the fireplace needs to be covered and made inaccessible to the clients
  • the required Tile 22 perishable and non-perishable foods must be purchased and maintained on the premises prior to the the acceptance of the first client
  • night lights must be placed in the hallways
  • all personal items stored in the bedrooms need to be removed
  • extra bedding and linens need to be purchased to allow for changing weekly or as needed
  • extra towels consisting of bath towels, hand towels and face towels need to be made available to allow for changing
  • blankets need to be provided to the clients
  • the temperature on the water heater needs to be adjusted to meet Title 22 requirements. Water temperature should fall within the range of 105-120 degrees Fahrenheit.
  • the front yard and backyard needs general cleaning to address the weeds, discarded items such as old brooms, sticks, bricks and dried leaves need to be removed.

Applicant will notify LPA Yee when the above corrections have been completed.

Component III was not conducted with the Applicant on today's visit due to the applicant having an afternoon appointment.

Exit interview was conducted and a copy of this report was provided.
SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Christine Yee
LICENSING EVALUATOR SIGNATURE:

DATE: 05/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2023
LIC809 (FAS) - (06/04)
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