195850534-1-8-2025-29-AS-TBYE-DCQRWP-20250108122328

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 195850534
Report Date: 01/08/2025
Date Signed: 01/08/2025 12:23:43 PM

Document Has Been Signed on 01/08/2025 12:23 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:	COMPLETE HARMONY BOARD AND CARE INC		FACILITY NUMBER:	195850534
ADMINISTRATOR/ DIRECTOR:	MARTINYAN,NURITSA		FACILITY TYPE:	740
ADDRESS:	14912 GILMORE ST		TELEPHONE:	(818) 425-2317
CITY:	VAN NUYS	STATE: CA	ZIP CODE:	91411
CAPACITY: 6		CENSUS: 4	DATE:	01/08/2025
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:59 AM
MET WITH:	Nurista Martinyan		TIME VISIT/ INSPECTION COMPLETED:	12:30 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) Trevor Byrne conducted a pre-licensing visit to the above noted facility. The LPA met with applicant, Nurista Martinyan. This is a change of ownership application. A dementia program was included in the plan of operation. A Hospice Waiver has been requested. The facility is one story. At 09:59 AM, a physical plant tour was conducted inside and out. An approved fire clearance was received, clearing them for six (6) non-ambulatory residents one (1) of which may be bedridden. The facility has two (2) private resident bedrooms, Rooms three (3) and four (4) and two (2) shared rooms, rooms one (1) and two (2). Rooms #1 and #2 have direct exits to the outside. All 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, blanket and a bedspread. Lighting in the rooms appeared adequate. The bedrooms were large enough to allow for easy passage between the beds and furniture with a wheelchair or walker. In addition, no bedroom was used as a passageway to another room, bath or toilet. There is no staff bedroom, awake night staff only is required. All rooms were free of odors. All window screens were clean and maintained in good repair. There is one (1) shared resident bathroom in the hallway and one (1) private resident bathroom attached to room #2. The resident bathrooms have a shower with non-skid materials. The toilet and showers have grab bars. The hot water temperature was tested in the bathrooms and was found to be within the range of 105F and 120F. Resident and staff records are stored in a locked cabinet which is currently located in the living room. Medications are centrally stored in a locked cabinet in the living room. The first aid supplies were complete, including a current version of the first aid manual. They were stored in the infection control station at the front entrance to the facility. Continued on LIC 809C.

SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Trevor Byrne
LICENSING EVALUATOR SIGNATURE:	DATE: 01/08/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/08/2025

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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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: COMPLETE HARMONY BOARD AND CARE INC	FACILITY NUMBER: 195850534
	VISIT DATE: 01/08/2025

NARRATIVE

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Kitchen knives are stored in a locked box in a kitchen cabinet. Stove burners are rendered inaccessible to the residents by the installation of child-proofing devices. The supply of dishes, utensils, pots, pans and drinkware is adequate. The freezer was maintained at zero degrees Fahrenheit (0*F) and the refrigerator was maintained at 40*F. The supply of perishable and nonperishable food is adequate. There are no pesticides poisons, or toxins stored in any food storage area or preparation area with utensils. Appliances in the kitchen were clean and all appeared functional. Trash cans had tight fitting lids. Kitchen, laundry and house cleaning supplies are stored in locked cabinets located in the kitchen and the hallway bathroom. No flies or other vermin were observed.

The common areas were appropriately furnished, and the lighting was adequate. There is a television and other entertainment equipment, games and/or activity supplies in the living room. There was sufficient space to accommodate both indoor and outdoor activities. Night lights were maintained in hallways and passageways to nonprivate bathrooms. All ramps were secure and non-slippery and were positioned at the level where wheelchairs and walkers may enter and exit the facility safely. There is a fireplace in the living room. It is appropriately screened and there are no tools. Alarms on all exterior doors were engaged at the time of visit and functional. In addition, the physical plant is consistent with the submitted facility sketch/floor plan. The facility had emergency lighting, which included flashlights, or other battery powered lighting, and batteries. The facility has a furnace, which is able to heat rooms that residents occupy to a minimum of 68 degrees Fahrenheit; and, they have central air conditioning and are able to cool rooms to a comfortable range, not to exceed 85 degrees Fahrenheit.

The facility smoke alarm system is not hard wired. The smoke detector and carbon monoxide detectors were tested at 10:21 AM and functioned properly during the time of visit. There is one (1) fire extinguisher throughout the house. It was fully charged and did not exceed the expiration date.

Hot water was tested in each bathroom, which included the resident bathrooms; and, the hot water ranged from 116.4 to 113.9 degrees Fahrenheit. The laundry area is located in the hallway bathroom. The supply of extra bed and bath linens is adequate. Personal hygiene items (shampoos, soaps) were adequate and are stored in a locked cabinet under the bathroom sink. Extra incontinence supplies are stored in the hallway closet. There is a functioning telephone on the premises. The emergency exiting plans/sketch are posted throughout the facility in all resident rooms. Continued on LIC 809C.

SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Trevor Byrne
LICENSING EVALUATOR SIGNATURE:	DATE: 01/08/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/08/2025

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: COMPLETE HARMONY BOARD AND CARE INC	FACILITY NUMBER: 195850534
	VISIT DATE: 01/08/2025

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The emergency telephone numbers, and other required postings are posted in the entryway to the facility.

The exterior passageways were clean and clear of any obstructions. There is a covered patio area at the front of the house with tables and chairs where residents can sit. The entire property is fenced. The back and sides of the house are separated from the front yard by gates on either side of the home. There is a door gate with a self-latching mechanism for persons to enter the front yard. There are two (2) locked storage sheds in the back yard. One (1) shed belongs to the facility and contains extra wheelchairs, and bed supplies. There are not any bodies of water on the premises at the present time. At 10:36 AM LPA Byrne observed an unsecured hand saw located on the bottom shelf of a grill in the backyard of the facility. The Applicant immediately secured the saw.

COMP III orientation was completed with the applicant during this pre-licensing inspection.

This report will be sent to the Centralized Application Bureau (CAB). You will be notified by the CAB Analyst when your license has been approved. You are not allowed to begin operating until you have been notified that your license has been approved by the CAB Analyst. Failure to comply could affect approval of your license.

SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Trevor Byrne
LICENSING EVALUATOR SIGNATURE:	DATE: 01/08/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/08/2025

LIC809 (FAS) - (06/04)

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