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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195850385
Report Date: 01/27/2025
Date Signed: 01/27/2025 07:03:57 PM

Document Has Been Signed on 01/27/2025 07:03 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/
DIRECTOR:		SARGSYAN, MAYAFACILITY TYPE:
740
ADDRESS:14625 LEADWELL STREETTELEPHONE:
(818) 983-7224
CITY:VAN NUYSSTATE: CAZIP CODE:
91405
CAPACITY: 6CENSUS: 4DATE:
01/27/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:21 AM
MET WITH:Alexander Otiashvili, AdministratorTIME VISIT/
INSPECTION COMPLETED:
07:10 PM
NARRATIVE
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Licensing Program Analyst(LPA) Christine Yee conducted an unannounced required Annual Inspection using the complete CARE Inspection Tool. LPA Yee was let into the home by Marina Martirosian, Staff. Staff contacted the Administrator/Licensee, Alexander Otiashvili via telephone and he arrived at 10:44am to conduct the visit.
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 an approved hospice waiver for 6 residents.

The following was observed on today's visit:
  • Staff and resident files were incomplete and were missing majority of the required documents and did not meet Title 22 requirements
  • Staff have current first aid training. Evidence of first aid/CPR training expires on 6/17/1925
  • Staff #1 does not have a criminal record clearance
  • The facility has liability insurance that meets Title 22 requirements of $1 million per incident and $3 million total annual aggregate.
  • The facility does not have training logs/evidence of in-service training conducted.
  • There are no completed Admissions Agreements.
  • Physician's Reports available are not signed and indicate that 2 residents' are considered bedridden. The Administrator will obtain clarification and provide a copy of the updated Physician's Reports to the Department. Citations and Civil penalties will be issued if needed once clarification is obtained.
  • All four residents are on hospice and there are not care plans, services being provided and evidence of staff training.
  • Administrator Certificate for Alexander Otiashevili expires on 5/8/26.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Christine Yee
LICENSING EVALUATOR SIGNATURE: DATE: 01/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/27/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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: 01/27/2025
NARRATIVE
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Deficiencies were cited under California Code of Regulations, Title 22, Division 6, Chapter 8. Civil Penalties were assessed.

Deficiencies not addressed on today's visit will be addressed on a return visit.


Exit interview was conducted, Appeals Rights were discussed and a copy was provided.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Christine Yee
LICENSING EVALUATOR SIGNATURE:

DATE: 01/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2025
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Document Has Been Signed on 01/27/2025 07:03 PM - It Cannot Be Edited


Created By: Christine Yee On 01/27/2025 at 05:29 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: CARE OF HEART
FACILITY NUMBER: 195850385

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/27/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87355(e)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 1 out of 2 staff files reviewed, Marina Martirosian. Staff did not obtain a criminal record clearance and is not associated to the facility prior to working, residing or volunteering in a licensed facility, which poses an immediate health, safety or personal rights risk to persons in care. CIVIL PENALTIES IN THE AMOUNT OF $500 WERE ASSESSED
POC Due Date: 01/28/2025
Plan of Correction
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The Licensee will submit a written plan to the Department as to how they will ensure that all staff, volunteers and individuals that need a criminal record clearance have received a criminal record clearance prior to being present at the facility by 1/18/25. The Licensee will also submit evidence that Marina Martirosian has received a criminal record clearance prior to her being present at the facility.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Kristin Heffernan
LICENSING EVALUATOR NAME:Christine Yee
LICENSING EVALUATOR SIGNATURE:
DATE: 01/27/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/27/2025


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Document Has Been Signed on 01/27/2025 07:03 PM - It Cannot Be Edited


Created By: Christine Yee On 01/27/2025 at 05:29 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: CARE OF HEART
FACILITY NUMBER: 195850385

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/27/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(f)
Personnel Requirements - General
(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health.Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above it was observed that Marina Martirosian does not evidence of a physical with the results of a TB test on file, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/03/2025
Plan of Correction
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The Licensee will ensure that all staff submit to a physical or provide evidence of a recent physical conducted that includes the results of a TB test. LIcensee will provide the Department with evidence that a physical was conducted with the results of the TB test by 2/3/25.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Kristin Heffernan
LICENSING EVALUATOR NAME:Christine Yee
LICENSING EVALUATOR SIGNATURE:
DATE: 01/27/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/27/2025


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Document Has Been Signed on 01/27/2025 07:03 PM - It Cannot Be Edited


Created By: Christine Yee On 01/27/2025 at 05:29 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: CARE OF HEART
FACILITY NUMBER: 195850385

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/27/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(a)
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the Administrator's file contained evidence of first aid training and evidence of a criminal record exemption and Martina Martirosian's file had evidence of first aid training and a request for a live scan, the licensee, did not comply with the section cited above in 2 out of 2 files reviewed which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/03/2025
Plan of Correction
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Licensee will ensure that personnel records are maintained on the licensee, administrator, each employee and volunteers. Each personnel record shall contain records indicated in Title 22 Section 87412 and all relevant sections related to personnel records.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Kristin Heffernan
LICENSING EVALUATOR NAME:Christine Yee
LICENSING EVALUATOR SIGNATURE:
DATE: 01/27/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/27/2025


LIC809 (FAS) - (06/04)
Page: 5 of 6
Document Has Been Signed on 01/27/2025 07:03 PM - It Cannot Be Edited


Created By: Christine Yee On 01/27/2025 at 05:29 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: CARE OF HEART
FACILITY NUMBER: 195850385

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/27/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(d)
(d) All personnel shall be given on the job training or have related experience in the job assigned to them. This training and/or related experience shall provide knowledge of and skill in the following, as appropriate for the job assigned and as evidenced by safe and effective job performance:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above per review of Marina Martirosian's file, there is not evidence that the staff was provided with the required trainings prior to providing care to the residents which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/03/2025
Plan of Correction
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The Licensee will provide the Department with a written plan as to how they will ensure that all staff are provided with the required training at time of hire and annually thereafter. The trainiing logs should indicate the date of training, subject of training, who attended, hours of training, training material and the instructor with contact information. Provide the Department with the written plan by 2/3/25.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Kristin Heffernan
LICENSING EVALUATOR NAME:Christine Yee
LICENSING EVALUATOR SIGNATURE:
DATE: 01/27/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/27/2025


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