195850423-9-16-2025-29-AS-ZCHN-DLKUQS-20250916154738

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 195850423
Report Date: 07/24/2025
Date Signed: 09/16/2025 03:49:37 PM

Document Has Been Signed on 09/16/2025 03:49 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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	IVY PARK AT WOODLAND HILLS		FACILITY NUMBER:	195850423
ADMINISTRATOR/ DIRECTOR:	O'GRADY, PATRICE		FACILITY TYPE:	740
ADDRESS:	20461 VENTURA BLVD.		TELEPHONE:	(818) 346-9046
CITY:	WOODLAND HILLS	STATE: CA	ZIP CODE:	91364
CAPACITY: 127		CENSUS: 68	DATE:	07/24/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:27 AM
MET WITH:	Lilit Mnatsakanyan		TIME VISIT/ INSPECTION COMPLETED:	04:00 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) Zabel Chochian conducted a required annual visit. LPA met with the new Executive Director (ED), Lilit Mnatsakanyan, and explained the reason for the visit. The facility is a (five) 5 story building including an underground garage. At approximately 10A.M., LPA observed the posting of required documents near the entrance of the facility. The common areas were observed to be properly furnished and relatively clean at the of the visit. At the time of the visit, living room and dining room furniture was observed to be in good condition. The facility maintained a comfortable temperature at the time of visit. A physical plant tour of the inside and outside of the facility with the ED. There are fire sprinklers and fire doors throughout the facility. Emergency/disaster drills are conducted monthly. Last fire drill was conducted on 07/15/2025. LPA inspected the common areas throughout the facility including the Activity room, Lobby, reading room, lounge, café, health center. All the rooms have been appropriately furnished. All exits in Memory care have functioning auditory devices and were operational at the time of the visit. There is an evacuation chair in each stair well on each side of the building. LPA inspected eight (8) randomly selected rooms in all four (4) floors including the memory care unit. resident rooms are set up with beds, nightstands, lamps, chests of drawers, chairs and closet space. The beds are furnished with box springs, comfortable mattress and clean linen; which includes, a mattress pad, top and bottom linens, pillowcases, and a bedspread. All rooms had a comfortable room temperature of 75 degrees Fahrenheit. Hot water temperature was measured in all eight (8) bathrooms and they were between the temperature range of 105-120 degrees Fahrenheit. Lighting in the rooms appeared adequate. All rooms were free of odors. All window screens were clean and maintained in good repair. The resident bathroom(s) have a shower with non-skid materials. The toilets were in working conditions and the showers observed with grab bars. (Continued on LIC 809-C)

NAME OF LICENSING PROGRAM MANAGER: Desaree Perera
NAME OF LICENSING PROGRAM ANALYST: Zabel Chochian
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 07/24/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2025

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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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)

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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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: IVY PARK AT WOODLAND HILLS	FACILITY NUMBER: 195850423
	VISIT DATE: 07/24/2025

NARRATIVE

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The kitchen was observed to be inaccessible to residents in care. Knives are kept inaccessible to residents in care. Kitchen appliances were observed to be in operable condition. The facility has a sufficient supply of perishable and non-perishable food. Dining room furniture were observed to be in good condition and appeared to be relatively clean. The supply of dishes, utensils, pots, pans and drink ware is adequate. The freezer was maintained at zero degrees Fahrenheit (0*F) and the refrigerator was maintained at 40*F. There are no pesticides (poisons) or toxins stored in any food storage area or preparation area with utensils. No flies or other vermin were observed. At approximately 1:06PM - 1:12PM, LPA observed ice cream, sauces, vegetables and other items stored in the freezer uncovered. Also, pies and other deserts observed in the refrigerator that were made a day or two ago according to the Executive Chef, were observed uncovered in the refrigerator.

Resident records review began at 2:30 P.M. Eight (8) resident records were reviewed for, but not limited to: appraisals, medical records, admissions agreement, consent forms. Staff records review began at 1:30 P.M, Eight (8) personnel records were reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, first aid/CPR training, and the appropriate training.

All records were observed to be in order at this time. The first aid supplies were complete, including a thermometer and a current version of a first aid manual. the main two (2) first aid kits were observed in the memory care director office and the health service office. Medications are stored in a medication cart which are kept in each floor and inaccessible to residents in care.

Medications review began at approximately 12P.M. Medications are documented on a centrally stored log printed by the pharmacy and maintained in a folder in a drawer in the medication room. Random sample review of residents medication completed during visit. Current procedures in place by ED and LVN with regards to record keeping. Centrally Stored records are being moved into binders for easy access.

Entry/exits were free of obstructions. The outdoor areas were clean and free of hazards. The patios and balconies observed have proper furnishings. There were no bodies of water noted.

Pursuant to Title 22 of the CA Code of Regulations, the following deficiency was cited (refer to LIC 809-D): Exit inter view conducted and copy of the report and appeal rights provided.

NAME OF LICENSING PROGRAM MANAGER: Desaree Perera
NAME OF LICENSING PROGRAM ANALYST: Zabel Chochian
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 07/24/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 09/16/2025 03:49 PM - It Cannot Be Edited

Created By: Zabel Chochian On 07/24/2025 at 03:18 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: IVY PARK AT WOODLAND HILLS	FACILITY NUMBER: 195850423
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/24/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87555(b)(23)

General Food Service Requirements

(b) The following food service requirements shall apply: (23) All readily perishable foods or beverages capable of supporting rapid and progressive growth of micro-organisms which can cause food infections or food intoxications shall be stored in covered containers at appropriate temperatures. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interview, the licensee did not comply with the section cited above. Food such as vegetables, ice cream, pies and other items observed stored in the freezer and refrigerator observed uncovered. This poses a potential health and safety risk to persons in care.
	POC Due Date: 07/31/2025
	Plan of Correction
1 2 3 4	Executive Director agreed to submit a plan of correction to ensure future compliance with section cited. Also provide in-service for kitchen staff.

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.

	Desaree Perera
NAME OF LICENSING PROGRAM MANAGER:

	Zabel Chochian
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/24/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2025

LIC809 (FAS) - (06/04)

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