197607404-7-28-2025-29-AS-QHUH-DJZPB8-20250728110954

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197607404
Report Date: 07/28/2025
Date Signed: 07/28/2025 11:10:05 AM

Document Has Been Signed on 07/28/2025 11:10 AM - 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:	CREATIVE MINDS ADP, INC.		FACILITY NUMBER:	197607404
ADMINISTRATOR/ DIRECTOR:	JOSE CHAVEZ		FACILITY TYPE:	775
ADDRESS:	6045 WOODMAN STREET		TELEPHONE:	(818) 780-1641
CITY:	VAN NUYS	STATE: CA	ZIP CODE:	91401
CAPACITY: 105		CENSUS: 55	DATE:	07/28/2025
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:13 AM
MET WITH:	Jaklen Keshishyan - Chief of Operations		TIME VISIT/ INSPECTION COMPLETED:	11:15 AM

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) Quoc Huynh conducted an unannounced Case Management for a self-reported incident that occurred on 07/17/2025 at 9:13AM. LPA met with Chief of Operations (COO) Jaklen Keshishyan and explained the reason for the visit. Entrance interview conducted. Between 9:20AM and 10:45AM, the LPA interviewed three (3) Staff, reviewed two (2) client files, and reviewed and obtained video footage of the incident. Beginning at 10:50AM, the LPA and COO conducted a brief tour of the physical plant areas to ensure there were no health and safety hazards. No immediate concerns were observed. It was reported on 07/17/2025 that Client #1 (C1) and Client #2 (C2) participated in a consensual sexual altercation in the clients’ restroom. Video footage of the hallway showed C2 walking to the restroom at 1:05PM and C1 following at 1:06PM. Staff #1 (S1) was observed to follow C1 and remained in the hallway monitoring C1 through a reflective mirror. S1 stated Staff #2 (S2) advised S1 to keep an eye on C1 as they were headed toward the restroom. Between 1:07PM and 1:10PM, several clients were observed entering and exiting the restroom. At 1:11PM, the restroom hallway camera footage showed C1 and C2 conversing through the restroom doorways. Report Continued on LIC 809-C

NAME OF LICENSING PROGRAM MANAGER: Kristin Heffernan
NAME OF LICENSING PROGRAM ANALYST: Quoc Huynh
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 07/28/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2025

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 N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: CREATIVE MINDS ADP, INC.	FACILITY NUMBER: 197607404
	VISIT DATE: 07/28/2025

NARRATIVE

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C1 began to inch forward out of the Men’s restroom with their phone in hand and took a photo. C1 then entered the Women’s restroom at 1:12:40PM and immediately retreated to the Men’s restroom as they heard Staff approaching at 1:12:50PM. In the subsequent hallway footage, S1 was seen notifying S2 and S2 immediately responded to the clients’ restroom and arrived at 1:12:54PM. C1 then refused to exit the Men’s restroom, and several Staff were seen attempting to talk C1 out of the restroom. C2 was captured exiting the restroom and returned to the day program at 1:17PM. C1 was escorted out of the Men’s restroom by Staff at 1:35PM.

Interview with the COO and Program Director Jose Chavez revealed that Staff frequently monitor the clients’ restrooms, however, will not go inside. C1 and C2 had a history of similar behavior, and the facility took preventative measures and provided extra support to the clients. After the incident on 07/17/2025, C1’s participation of the day program was terminated and C2 received a temporary suspension. C2 has since been referred to the 1:1 day program and is awaiting authorization from the Regional Center.

Based on the information reviewed and obtained, there was not a lack of supervision for C1 and C2 during the incident. No further follow up is needed at this time and no deficiency cited. A follow-up visit will be conducted if warranted.

Exit interview conducted. A copy of today’s report was reviewed and provided.

NAME OF LICENSING PROGRAM MANAGER: Kristin Heffernan
NAME OF LICENSING PROGRAM ANALYST: Quoc Huynh
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 07/28/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2025

LIC809 (FAS) - (06/04)

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