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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607892
Report Date: 04/04/2025
Date Signed: 04/04/2025 02:47:39 PM

Document Has Been Signed on 04/04/2025 02:47 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: DATE:
04/04/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:20 PM
MET WITH:Gevorg Mkrtchian - LicenseeTIME VISIT/
INSPECTION COMPLETED:
03:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Quoc Huynh arrived at the facility unannounced for a required one year visit. LPA arrived at 12:20PM and met with Avelino Frigillana who then called facility Administrator. Administrator Gevorg Mkrtchian arrived at 12:42PM. Entrance interview conducted.

Beginning at 12:45PM, a tour of the physical plant was conducted to ensure clients’ health and safety and the facility is in compliance with Title 22 regulations. The facility is a Regional Center Level 3 one story home. The following was observed:

KITCHEN: Appliances and fixtures appeared clean and functional. The facility had a sufficient supply of perishable and non-perishable food. Knives and other sharps are stored inaccessible in a locked cabinet to the right of the fridge. Kitchen and house cleaning supplies are stored in a locked cabinet located under the sink. Laundry room is located to the left of the kitchen with a locked cabinet containing detergent and other supplies.

COMMON AREAS: These include the Family Room and Dining Room. All furniture appeared clean and in good condition. There was sufficient space to accommodate both indoor and outdoor activities. Fire extinguishers were observed throughout the common areas and were last serviced on 04/09/2024. Combination smoke detectors and carbon monoxide detectors were tested at 1:00PM and were functional.

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: 04/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/04/2025
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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Document Has Been Signed on 04/04/2025 02:47 PM - It Cannot Be Edited


Created By: Quoc Huynh On 04/04/2025 at 02:32 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: 04/04/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in which poses/posed a potential health, safety or personal rights risk to persons in care.

At 12.50PM, water temperature was tested and measured at 125.6 degrees F. After adjusting the water heater, water temperature measured at 112.5 degrees F at 1:45PM.
POC Due Date: 04/18/2025
Plan of Correction
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Administrater Gevorg Mkrtchian agreed to measure water temperature twice a day (9AM and 5PM) and document it for the next two weeks and submit proof to CCL by POC due 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.
Kristin Heffernan
NAME OF LICENSING PROGRAM MANAGER:
Quoc Huynh
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/04/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/04/2025


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: CHRISTINE'S RETREAT
FACILITY NUMBER: 197607892
VISIT DATE: 04/04/2025
NARRATIVE
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BEDROOMS: The facility has four (4) bedrooms; one (1) is a designated staff room and three (3) shared client rooms. All bedrooms were observed to contain appropriate furniture, bedding and linens. There were no visible hazards or inconsistencies observed.

BATHROOMS: There are two (two) bathrooms; one (1) is located in the hallway and is designated for shared client use and one (1) is a private bathroom attached to one shared room. All bathrooms were observed to be clean and sanitary and supplied with appropriate paper and hygiene products. At 12.50PM, water temperature was tested and measured at 125.6 degrees F. After adjusting the water heater, water temperature measured at 112.5 degrees F at 1:45PM.

SURROUNDING GROUNDS: Exterior passageways were clean and clear of any obstructions. There is one (1) side gate with a self-latching mechanism for persons to exit the backyard in emergencies.

CLIENT FILE REVIEW: LPA reviewed four (4) client file records at 1:05PM. Client records were reviewed for, but not limited to care plans, physician's report, admissions agreement, and consent forms. Client files reviewed contained all required documents.

STAFF FILE REVIEW: LPA reviewed three (3) staff records during today's visit. Personnel records were reviewed for, but not limited to health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All staff records reviewed were in compliance at the time of the visit.

MEDICATION REVIEW: LPA reviewed medications at 2:15PM. Two (2) clients’ medications were reviewed and observed to be stored and administered in compliance with regulation.

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

DATE: 04/04/2025
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: CHRISTINE'S RETREAT
FACILITY NUMBER: 197607892
VISIT DATE: 04/04/2025
NARRATIVE
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INFECTION CONTROL/EMERGENCY DISASTER PLANNING: During today’s visit, the LPA reviewed the facility's infection control plan as well as the facility's emergency disaster plan. The facility’s policies and procedures as it pertains to infection control are adequate. Emergency disaster plan was observed to be complete and recently updated. Emergency disaster drills are conducted quarterly with the last one on 03/01/2025.

Pursuant to Title 22 of the CA Code of Regulations, the following deficiency was cited. (refer to LIC 809-D).

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

DATE: 04/04/2025
LIC809 (FAS) - (06/04)
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