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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195850385
Report Date: 12/20/2023
Date Signed: 12/20/2023 03:04:33 PM

Document Has Been Signed on 12/20/2023 03:04 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:CARE OF HEARTFACILITY NUMBER:
195850385
ADMINISTRATOR:SARGSYAN, MAYAFACILITY TYPE:
740
ADDRESS:14625 LEADWELL STREETTELEPHONE:
(818) 983-7224
CITY:VAN NUYSSTATE: CAZIP CODE:
91405
CAPACITY: 6CENSUS: 1DATE:
12/20/2023
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
08:48 AM
MET WITH:Alexander Otiashvili, ApplicantTIME COMPLETED:
03:05 PM
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Licensing Program Analyst(LPA) Christine Yee conducted a announced Prelicensing and Component III visit and used the CARE Inspection Tool. LPA Yee met with Alexander Otiashvili, Applicant and Maya Sargsyan, Designated Administrator.

The home is a single storey family home consisting of a living room, dining room, kitchen, 3 bedrooms, a private and a common bathroom. The home is fire cleared for 6 non-ambulatory residents. The facility has a waiver for 6 residents.

The following were observed on today's visit:
  • the living room is furnished with the appropriate seating, coffee table and a portable electric fire cabinet.
  • the dining room has a table with 6 chairs. Located in the dining room is a locked storage cabinet to be used to store the centrally stored medications and a little cabinet for resident and staff files.
  • the kitchen is equipped with a dishwasher, stove and a microwave. Sufficient perishable and non-perishable foods were observed. Knives are locked in a locked kitchen drawer. Sufficient, utensils, dinner plates, salad plates, bowls, cups, pots and pans were observed. The only fire extinguisher, purchased on 11/12/23 is located between the kitchen and dining room.
  • Bedroom #1 is furnished with 2 twin beds, 2 night stands, 2 lamps, 2 padded seats, 2 dressers and a shared closet. Required linens were observed and extra linens and towels are stored in the residents' closet.
  • Bedroom #2 is furnished with 2 hospital beds, 3 night stands, 2 lamps, 2 chairs, 2 dressers and a large walk in closet. Required linens were observed on the bed and extra linens, blankets and towels were observed in the residents' closet. The slate of the window blinds are warped. Located inside bedroom #2 is a private bathroom equipped with a shower stall, a toilet and a sink. Grab bars and a non-skid mat were observed. Water temperature was tested and read 117.6 degrees Fahrenheit.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Christine Yee
LICENSING EVALUATOR SIGNATURE: DATE: 12/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/20/2023
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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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: CARE OF HEART
FACILITY NUMBER: 195850385
VISIT DATE: 12/20/2023
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  • Bedroom #3 is furnished with 2 full size beds, 2 night stands, 2 chairs, 2 lamps, a shared closet and 2 dressers that do not met Title 22 requirements of 8 cubic feet. Extra linens, blankets and towels were observed. The slates on the window blinds are warped
  • the common bathroom is equipped with a shower stall, a toilet and a sink. Grab bars and non-skid mat was observed. Water temperature was tested and read 117.2 degrees Fahrenheit.
  • the hardwired smoke detectors were tested and were operational.
  • the hardwired carbon monoxide detector located in the living room and in the hallway were tested and were operational.
  • night lights were observed in the hallway and in the bathrooms
  • a first aid kit with the required bandages, gauze, tweezer, scissors and thermometer were observed.
  • per the applicant a first aid manual was ordered but has not arrived.
  • the facility has a landline telephone. Telephone # is (747)264-0332
  • the backyard was observed to be clean and equipped with a tent, rattan chairs, a metal armchair and bench. Storage shed and cabinets used to store toxins and extra items were observed. Trash cans with tightly sealed covers were observed. Applicant needs to store or discard cardboard boxes, scooter, desk and hospital table. No bodies of water was observed
  • the front yard is clean and used for tenant parking
  • Applicant has received a insurance quote for liability insurance that meets Title 22 requirements.

The following needs to be corrected prior to licensure:
  • the warped slates of the window blinds in bedroom #2 and bedroom #3 need to replaced
  • dressers that meet Title 22 requirements of 8 cubic feet per person needs to be provided.
  • evidence of a first aid manual needs to be provided
  • the items that were observed in the backyard need to be discarded or stored away

Applicant needs to purchase liability insurance once the facility is licensed

COMPONENT III was conducted with Alexander Otiashvili and Maya Sargsyan.

Exit interview was conducted.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Christine Yee
LICENSING EVALUATOR SIGNATURE:

DATE: 12/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2023
LIC809 (FAS) - (06/04)
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