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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195850430
Report Date: 05/16/2025
Date Signed: 05/28/2025 05:49:47 PM

Document Has Been Signed on 05/28/2025 05:49 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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:ANGELS HANDS SENIOR LIVINGFACILITY NUMBER:
195850430
ADMINISTRATOR/
DIRECTOR:		GHUKASYAN, MARINEFACILITY TYPE:
740
ADDRESS:14819 VALERIO STREETTELEPHONE:
(818) 679-4442
CITY:VAN NUYSSTATE: CAZIP CODE:
91405
CAPACITY: 6CENSUS: 3DATE:
05/16/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:30 AM
MET WITH:Marine Ghukasyan, AdministratorTIME VISIT/
INSPECTION COMPLETED:
06:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Christine Yee conducted an unannounced required Annual Inspection visit and used the CARE Inspection Tool. LPA Yee met with Marine Ghukasyan, Administrator. The reason for today's visit was provided.

The home is a single storey family home consisting of a living room, dining room, family room, kitchen, 4 bedrooms of which one will be used for live-in staff and as an office, 2 full bathrooms and a attached garage. The facility is fire cleared for 5 NON-AMBULATORY and 1 BEDRIDDEN residents. Bedroom #2 is the room designated for bedridden use.

On today's visit, LPA Yee reviewed 3 resident files and 4 staff files, reviewed medications and Medication Administration Record for Resident #3 and attempted to complete the infection control domain but was able to answer 32 questions only.
The following were observed on today's visit:
  • All three residents are receiving PRN medications but there are no completed PRN Authorization Letters on file to determine if the residents are able or unable to request their medications if needed or if staff should be contacting the physician for instructions prior to administrating the medications based on the residents' symptoms. During this visit, LPA Yee observed the Administrator dispense a pain pill to Resident #3 and it was refused by the resident. No contact was made with the physician.
  • MAR logs are not being documented correctly. The daily MAR log is checked off when medications are dispensed and the staff dispensing the medication is unknown. The facility also keeps a separate MAR log for PRNs and cycle medications are included with a different time and looks like duplication of medications. Medication training was provided by the Administrator but documentation was unavailable.
NAME OF LICENSING PROGRAM MANAGER: Kristin Heffernan
NAME OF LICENSING PROGRAM ANALYST: Christine Yee
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/28/2025
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 6
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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: ANGELS HANDS SENIOR LIVING
FACILITY NUMBER: 195850430
VISIT DATE: 05/16/2025
NARRATIVE
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  • On 3/20/25 medication training was provided to 2 caregivers - Gevorg Gevshenyan and Armine Safaryan but medications dispensed are not being correctly documented as of today's visit.
  • Resident #2 does not have a physical with evidence of a TB test
  • Resident #3 does not have a completed Admissions Agreement on file.
  • The facility does not have documentation of any of the emergency fire drills that have been conducted in 2024 and has only conducted one fire drill on 1/16/25.


LPA Yee terminated the visit as the Administrator was not able to provide answers to the questions on the CARE Inspection Tool. Any deficiencies not addressed on today's visit will be addressed on a return visit.


Deficiencies cited under California Code of Regulations, Title 22, Division 6, Chapter 8.

Exit interview was conducted, Appeals Rights discussed and a copy was given.
NAME OF LICENSING PROGRAM MANAGER: Kristin Heffernan
NAME OF LICENSING PROGRAM ANALYST: Christine Yee
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2025
LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 05/28/2025 05:49 PM - It Cannot Be Edited


Created By: Christine Yee On 05/28/2025 at 10:52 AM
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: ANGELS HANDS SENIOR LIVING
FACILITY NUMBER: 195850430

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/16/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(b)
87465 Incidental Medical and Dental Care: (b) If the resident's physician has stated in writing that the resident is able to determine and communicate his/her need for a prescription or nonprescription PRN medication, facility staff shall be permitted to assist the resident with self-administration of his/her PRN medication.

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 3 out of 3 residents who receive PRN medications, the facility does not have completed PRN Authorization letters completed by the prescribing doctor on file to indicate whether the residents are able to determine and commuinicate his/her need for a prescription or non-prescription PRN medication which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/04/2025
Plan of Correction
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The Licensee will contact the prescribing doctor for all PRN medications and obtain a completed PRN Authoriization Letter that determines whether the residents are/are not able to determine and communicate their need for a PRN medication and maintain in the residents files and a copy is to be faxed to CCLD by 6/4/25.
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.
Kristin Heffernan
NAME OF LICENSING PROGRAM MANAGER:
Christine Yee
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/28/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/28/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/28/2025 05:49 PM - It Cannot Be Edited


Created By: Christine Yee On 05/28/2025 at 12:28 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: ANGELS HANDS SENIOR LIVING
FACILITY NUMBER: 195850430

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/16/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(d)(4)
87411 Personnel Requirements – General: All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69. 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: (4) Knowledge required to safely assist with prescribed medications which are self-administered.

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 as the MAR logs for dispensed medications are not being accurately documented and initial training was provided by the Administrator and later by an RN and yet the documentation indicates that the residents are being provided PRN medications and cycle medications multiple times a day in excess of what is prescribed, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/04/2025
Plan of Correction
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The Licensee will obtain the services of a pharmacist or a medical professional to obtain re-training for the Administrator and all staff responsible for assisting residents with their medications with the proper process of dispensing medications and documenting the MAR log and completing notes for the PRN medications dispensed with the date, time, dosage, reactions and the outcome or any instructions obtained from contact with the prescribing doctor by 6/4/25
Type B
Section Cited
CCR
87458(c)(1)(A-D)
87458 Medical Assessment: (c) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the licensed medical professional's diagnosis or diagnoses and results of an examination for all of the following: (A) Communicable tuberculosis. (B) Infectious diseases. (C)Contagious diseases. (D) Other medical conditions.

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 3 files reviewed that Resident #2 did not have a Physician's Report with the results of a TB test which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/04/2025
Plan of Correction
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The Licensee will contact Resident #2's physician or schedule a visit to obtain a TB test and the results of the test and maintain in Resident #2's file and a copy of this report will be be faxed to CCLD by 6/4/25
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Kristin Heffernan
NAME OF LICENSING PROGRAM MANAGER:
Christine Yee
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/28/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/28/2025


LIC809 (FAS) - (06/04)
Page: 6 of 6
Document Has Been Signed on 05/28/2025 05:49 PM - It Cannot Be Edited


Created By: Christine Yee On 05/28/2025 at 12:55 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: ANGELS HANDS SENIOR LIVING
FACILITY NUMBER: 195850430

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/16/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87507(a)
87507 Admission Agreements: (a) The licensee shall complete an individual written admission agreement, as defined in Section 87101(a), with each resident or the resident's representative, if any.

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 of 3 files reviewed, Resident #3 does not have a completed Admission Agreement on file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/04/2025
Plan of Correction
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Licensee will contact Resident #3's responsible party to complete an Admission Agreement and provide a copy to the responsible party and the resident and retain the original in the resident's file by 6/4/25. A copy will also be provided to CCLD by 6/4/25. ***********a copy of Admission Agreement observed on visit conducted on 5/28/25*******
Type B
Section Cited
HSC
1569.695(c)
§1569.695 Emergency Plans: (c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

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 as there was no evidence that quarterly drills were conducted at all in 2024 and one was conducted in January 2025. No other drills have been conducted since then which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/04/2025
Plan of Correction
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Licensee will ensure that a drill is conducted by 6/4/25 for each shift and every quarter thereafter. Each drill will be documented with the date and time it was conducted, the names of the staff and residents who participated and the event that was simulated. A copy of the current drill conducted will be provided to CCLD by 6/4/25.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Kristin Heffernan
NAME OF LICENSING PROGRAM MANAGER:
Christine Yee
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/28/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/28/2025


LIC809 (FAS) - (06/04)
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