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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607892
Report Date: 04/19/2024
Date Signed: 04/19/2024 03:49:42 PM

Document Has Been Signed on 04/19/2024 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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:CHRISTINE'S RETREATFACILITY NUMBER:
197607892
ADMINISTRATOR/
DIRECTOR:		GEVORG MKRTCHIANFACILITY TYPE:
735
ADDRESS:14712 KILLION STREETTELEPHONE:
(818) 387-8572
CITY:SHERMAN OAKSSTATE: CAZIP CODE:
91411
CAPACITY: 6CENSUS: 3DATE:
04/19/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:15 PM
MET WITH:Marsha J WilliamsTIME VISIT/
INSPECTION COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Valeria Conway arrived at the facility to conduct an unannounced Required Annual inspection. At 12:16 p.m., LPA met with staff Remedios Frigillana who then contacted assistant administrator Marsha Williams via phone. Administrator stated that she would arrive shortly and advised staff Remedios Frigillana to assist LPA. Assistant administrator arrived at approximately 1:13 p.m. Entrance interview conducted and the reason for the visit was explained.

LPA was informed by staff that there are three (3) clients in the home. At the time of visit two (2) clients were attending program, and one (1) client was observed watching television (TV). The facility serves level 3 clients from North Los Angeles County Regional Center. One (1) staff observed during the visit.

At approximately 12:30 p.m. LPA toured the facility with staff.

Bedrooms: All clients bedrooms were properly furnished with a bed, nightstand, and sufficient lighting for each resident. The bedrooms had appropriate and adequate bedding and linens such as sheets, pillowcases, mattress pads, and blankets. LPA observed a sufficient supply of linen and personal hygiene supplies in the closet.

Bathrooms: LPA observed bathrooms to be clean, properly supplied with soap and paper towels/ had functional fixtures. The hot water measured in both bathrooms to be between 108.9 and 109.6 degrees Fahrenheit.

Continued on LIC 809-C

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Valeria Conway
LICENSING EVALUATOR SIGNATURE: DATE: 04/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/19/2024
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: CHRISTINE'S RETREAT
FACILITY NUMBER: 197607892
VISIT DATE: 04/19/2024
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Continued from LIC 809

Kitchen/Common areas: The living room and dining room were properly furnished and clean. The kitchen appeared to be clean and the appliances and fixtures functional. LPA observed sufficient amount of perishable and non-perishable food at the facility; properly stored. Sharp objects were observed locked in the kitchen cabinet. Medications and client files were observed locked in cabinets in the kitchen area as well. First aid kits properly supplied. Fire extinguishers were observed to be fully charged and last day served to be 04/09/2024. At 1:15 p.m. dual smoke/carbon monoxide detectors tested and functioned properly. Last emergency drill was conducted on 04/01/2024. LPA observed laundry area next to the kitchen. Cleaning supplies were observed to be locked in the cabinet. Staff rest area accessible from laundry. LPA was informed that this area is used as office space, storage and staff break area. Emergency food supply was also observed stored in staff area. LPA did not observe any obstructions to emergency exits at this time.

Outdoors: The backyard has a covered outdoor area equipped with furniture for resident use. There were no bodies of water noted. There is a side gate, LPA noticed that gate latch is broken assistant administrator stated that it will get fixed next week, and proof will be sent to LPA. LPA observed a sufficient amount of space for activities.

LPA also conducted a facility file review at 2:00p.m. and observed the Personnel Report (LIC500) is dated on 03/04/2020. LPA observed that Emergency disaster plan (LIC 610D) was inside a binder and date on 02/06/2016. Assistant administrator will update these forms and send proof to LPA.

Medications review began at 2:11 p.m. The medications are centrally stored and locked in a cabinet next to the kitchen. Medications are labeled and checked for expiration dates. Medications are properly documented on the centrally stored medications and destruction record.

At 2:26 p.m., staff files were reviewed. LPA observed Administrator certificate for Gevorg Mkrtchian expired on 07/19/2023 and assistant administrator’s Marsha Williams expired on 04/30/2023. Assistant administrator explained that she is working on getting her training done as soon as possible; however due to financial struggles she wasn’t able to get it renewed before her expiration date. For Mr. Mkrtchian was explained to LPA that he had some paperwork issues, and he is in communication with licensing department to get his certificate renewed.

Continued on 809-C

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Valeria Conway
LICENSING EVALUATOR SIGNATURE:

DATE: 04/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/19/2024
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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: CHRISTINE'S RETREAT
FACILITY NUMBER: 197607892
VISIT DATE: 04/19/2024
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Continued from LIC 809-C

At 3:00 p.m. LPA review client files and the following was observed. For Client #1 (C1) and Client #2 last needs and service plan was conducted in 2022 for Client #3 (C#) needs and services plan was missing Assistant administrator stated she will update it and send a copy to LPA.

Pursuant to Title 22 CA Code of Regulations, the following deficiency was cited (refer to LIC 9099-D). Administrator was informed failure to correct the deficiency may result in civil penalties. Administrative assistant was unable to complete the visit and authorized staff to sign and receive the report.

Exit interview conducted. A copy of the report and appeal rights were provided

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Valeria Conway
LICENSING EVALUATOR SIGNATURE:

DATE: 04/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/19/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/19/2024 03:49 PM - It Cannot Be Edited


Created By: Valeria Conway On 04/19/2024 at 03:33 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: CHRISTINE'S RETREAT
FACILITY NUMBER: 197607892

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/19/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85064(b)
Administrator Qualifications and Duties
(b) All adult residential facilities shall have a qualified and currently certified administrator.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on record review, the licensee did not comply with the section cited above in 2 out of 2 administrator certificates which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/03/2024
Plan of Correction
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2
3
4
Facility shall submit a copy of the current certificate or proof that renewal application was submited to the Department transaction is pending approval, as proof of correction to CCL by POC due date.
Type B
Section Cited
HSC
1565(d)
Other Provisions
(d) A facility shall review the plan annually and make updates as necessary, including changes in floor plans and the population served. The licensee, administrator, or regulated individual shall sign and date the documentation to indicate that the plan has been reviewed and updated as necessary.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based record review, the licensee did not comply with the section cited LIC 500 and Emergency Disaster Plan is outdated.
POC Due Date: 05/03/2024
Plan of Correction
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Facility shall submit a copy of these forms to the Department as proof of correction to CCL by POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Desaree Perera
LICENSING EVALUATOR NAME:Valeria Conway
LICENSING EVALUATOR SIGNATURE:
DATE: 04/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/19/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/19/2024 03:49 PM - It Cannot Be Edited


Created By: Valeria Conway On 04/19/2024 at 03:33 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: CHRISTINE'S RETREAT
FACILITY NUMBER: 197607892

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/19/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1565(e)(2)
Other Provisions
(e) A facility shall have all of the following information readily available during an emergency: (2) An appraisal of needs and services plan for each individual served by the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on record review, the licensee did not comply with the section cited above in 3 out of 3 clients which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/03/2024
Plan of Correction
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3
4
Facility shall submit a copy of the current Needs and Service plan as proof of correction to CCL by POC due date.
Section Cited
Deficient Practice Statement
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4
POC Due Date:
Plan of Correction
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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.
SUPERVISOR'S NAME:Desaree Perera
LICENSING EVALUATOR NAME:Valeria Conway
LICENSING EVALUATOR SIGNATURE:
DATE: 04/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/19/2024


LIC809 (FAS) - (06/04)
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