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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197604809
Report Date: 04/16/2025
Date Signed: 04/16/2025 03:52:02 PM

Document Has Been Signed on 04/16/2025 03:52 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 S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:CHATEAU MAGNOLIAFACILITY NUMBER:
197604809
ADMINISTRATOR/
DIRECTOR:		KARINE FILIKYANFACILITY TYPE:
740
ADDRESS:1061 EAST MAGNOLIA ST.TELEPHONE:
(818) 843-5873
CITY:BURBANKSTATE: CAZIP CODE:
91501
CAPACITY: 6CENSUS: 4DATE:
04/16/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:15 AM
MET WITH:Karine Filikyan - AdministratorTIME VISIT/
INSPECTION COMPLETED:
04:00 PM
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At 9:15 AM Licensing Program Analyst (LPA) Nadia Shahbazian, conducted an unannounced annual inspection at the facility mentioned above. LPAs met with the Karine Filikyan - Administrator and explained the reason for the visit. The total capacity of the facility is approved for six (6) non-ambulatory residents; six (6) of whom may be bedridden. Facility has an approved waiver for one (1) hospice resident. Facility is a single-story house consisting of a total of six (6) bedrooms, two (2) full bathrooms. Current census is (4) four residents, including one (1) on hospice care.

At 10:45am, with the assistance of administrator, LPA took a tour of the physical plant. Required postings were observed in the entry area. The smoke alarms and carbon monoxide detectors were tested and were functioning properly. The fire extinguisher is located in the kitchen. The charge date is 11/17/2024.



Kitchen: The kitchen appliances consisted of a refrigerator, oven and microwave, and all fixtures were functional. LPA found a sufficient supply of perishable (2 days) and non-perishable (7 days) foods at the facility. Knives were stored in a drawer in the kitchen but the lock was broken. Staff immediately removed the knives and placed them in the locked medication cabinet in the kitchen. Kitchen clleaning supplies are being stored in the kitchen, underneath the sink but the lock was broken. Staff immediately removed and locked the chemicals in the garage, inaccessible to the residents.

Bedrooms: There were five (5) bedrooms designated for residents' use and one (1) staff bedroom. The bedrooms in use by the residents were properly furnished with chairs, appropriate beddings and linens with sufficient lighting. One (1) of the bedrooms is currently vacant.

Bathrooms: There are two (2) bathrooms, one (1) designated for residents' use and one (1) for staff use. Both bathrooms have functional grab bars, non-skid mat, and fixtures. Hot water temperature in residents' bathroom was measured at 117.8 degrees Fahrenheit.

Common Areas: These included the living room, dining room and dining area in the kitchen. A properly covered fireplace was observed in the living room, even though the facility does not use the fireplace. The common areas were properly furnished with tables and chairs, appropriate with number of residents. The auditory alarms on all exit doors were observed and functional at the time of the visit. Facility is equipped with cameras in the common areas.

Continued on LIC 809-C
NAME OF LICENSING PROGRAM MANAGER: Eva Miller
NAME OF LICENSING PROGRAM ANALYST: Nadia Shahbazian
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/16/2025
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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: CHATEAU MAGNOLIA
FACILITY NUMBER: 197604809
VISIT DATE: 04/16/2025
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Garage: Facility has a detached garage which currently is used as storage space. The laundry is located inside the garage. LPA observed the laundry cleaning supplies, hazardous liquids, detergents locked in the garage, inaccessible to residents in care. LPA observed two extra refrigerators in the garage as well, supplied with perishable food supplies. Non-perishable emergency food supplies were also kept in the garage.

Back Yard/Emergency exists: The main entry door is used for entrance/emergency exit door. LPA observed a locked back gate, exit doors in room #4, room #6, living room and an unlocked side door in the backyard. The pathways were clear of obstruction. No body of water was observed. Patio is covered and furnished with outdoor furniture, appropriate for number of the residents.

Resident Files: LPA conducted a file review of resident records to ensure compliance of licensing forms.



Staff Files: LPA also conducted a file review of staff records to ensure forms and training are up to date and in compliance with licensing forms.

Medications: Properly labeled medications were locked in one of the kitchen cabinets. A complete first aid kit and the first aid manual were also observed, together with the medications, in the kitchen cabinet. Medication and Medication Records for four (4) out of four (4) residents were reviewed for proper documentation and administration.

Pursuant to Title 22 Division 6 of the CA Code of Regulations, deficiencies were cited (refer to LIC 809-D). Staff immediately corrected the deficiencies and the administrator will ensure staff are properly trained.

Exit Interview Conducted / Appeal Rights Discussed / A Copy of the Report Issued.

NAME OF LICENSING PROGRAM MANAGER: Eva Miller
NAME OF LICENSING PROGRAM ANALYST: Nadia Shahbazian
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/16/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/16/2025 03:52 PM - It Cannot Be Edited


Created By: Nadia Shahbazian On 04/16/2025 at 03:37 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., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: CHATEAU MAGNOLIA
FACILITY NUMBER: 197604809

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/16/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
This requirement is not met as evidenced by: Except as specified in subsection 87309(a), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage.
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/17/2025
Plan of Correction
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Staff immediately removed the knives/sharp objects and locked them in the medicine cabinet in the kitchen. Staff also removed the kitchen chemicals and detergents immediately and locked them in the garage. Administrator will ensure training is provided and will submit proof of training to LPA by the POC date.
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.
Eva Miller
NAME OF LICENSING PROGRAM MANAGER:
Nadia Shahbazian
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/16/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/16/2025


LIC809 (FAS) - (06/04)
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