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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197608319
Report Date: 04/21/2026
Date Signed: 04/21/2026 02:56:41 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/16/2026 and conducted by Evaluator Sandra Urena
COMPLAINT CONTROL NUMBER: 29-AS-20260416140351
FACILITY NAME:CHRISTINE'S RETREATFACILITY NUMBER:
197608319
ADMINISTRATOR:CHRISTINE MKRTCHIANFACILITY TYPE:
735
ADDRESS:17145 WILLARD STTELEPHONE:
(818) 578-8468
CITY:VAN NUYSSTATE: CAZIP CODE:
91406
CAPACITY:6CENSUS: 6DATE:
04/21/2026
UNANNOUNCEDTIME BEGAN:
10:12 AM
MET WITH:Gevorg MkrtchianTIME COMPLETED:
02:55 PM
ALLEGATION(S):
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Staff did not ensure documents were not missing from resident's records.
Staff did no safeguard resident's personal belongings.
Staff inappropriately put diapers on resident.
Staff did not have an inventory list for resident's personal belongings.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Sandra Urena conducted an initial unannounced 10- day visit to investigate the allegations listed above. The LPA met with the Administrator Gevorg Mkrtchian and explained the reason for the visit. AT the time of the visit, all six (6) residents are residing at a temporary relocation home, due to remodeling/construction work being done to the inside facility. Residents will be at the temporary location until 04/23/2026. Administrator reported that the residents will be moving to a new location because the rental lease will be up, and the Administrator has identified a new location for the temporary move till all the inspections have been completed.

LPA Urena, along with the Administrator, toured the physical plant areas inside and outside to inspect the
remodeling/construction work and get an update of the completion date. The Administrator reported that they have an appointment scheduled for 04/22/2026 with the Building and Safety Inspector. After the inspection passes, they will contact the Fire and Safety Inspector to conduct a visit.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Sandra Urena
LICENSING EVALUATOR SIGNATURE:

DATE: 04/21/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
Control Number 29-AS-20260416140351
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 197608319
VISIT DATE: 04/21/2026
NARRATIVE
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Staff inappropriately put diapers on resident.
It is the concern of the RP that R1 had disposable adult briefs, however per the R1’s Physician report, R1 is not incontinent. The LPA interviewed staff (S1). The interview with S1 revealed that the staff provided R1 with disposable adult briefs, because the facility were out of feminine pads, consequently the staff gave R1 the adult disposable briefs to wear in the meantime. When the LPA asked S1 how many times R1 had worn the disposable briefs, S1 stated, “two times”. The LPA interviewed the Administrator, and the interview revealed that they had purchased at least two bags of feminine pads and did not know why there were no pads available. Based on the information obtained through interviews, the allegation that staff inappropriately put diapers on R1, is deemed Substantiated at this time

Staff did not have an inventory list for resident's personal belongings.
It is the concern of the RP that the facility is not maintaining record of the residents’ belongings, as the facility has not been able to provide an inventory list (Record of Client/Resident Personal Property and Valuables (LIC 621), a record of each client’s personal property and/or valuables entrusted to the facility); which should have been maintained in R1’s records/binder. To investigate the allegation, LPA Urena interviewed the staff (S2) about the record keeping for clothing items. S2 reported that because the file for R1 was not available at the time R1 arrived at the facility, they took inventory in their notebook. The S2 showed the LPA the notebook with the date on the top of the page and two lists described as “new” and “old” (clothes). The Administrator’s interview revealed that they typically keep blank pages of the LIC621 to record the resident’s property and valuables when residents arrive at the facility and is not sure why the staff did not document the items in LIC 621 instead of their notebook. At the time of the visit, the LPA was able to confirm that the LIC 621 has not been completed and added to R1’s file.
Based on the information obtained through interviews, although the staff did document R1’s personal and property valuables, the staff did not complete the required form and presented it to the official at the time of the inspection. Therefore, the allegation of the missing inventory list, is deemed Substantiated at this time.

Pursuant to Title 22, California Code of Regulations (CCR), the following deficiencies were cited (refer to LIC 9099-D).

Citations were issued. Exit interview was conducted and a copy of the report and Appeal Rights were issued.

SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Sandra Urena
LICENSING EVALUATOR SIGNATURE:

DATE: 04/21/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 29-AS-20260416140351
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 197608319
VISIT DATE: 04/21/2026
NARRATIVE
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Once the inspections from the city and fire department have been completed the Administrator will email the LPA to inform them of the completion of the work and inspections. The LPA will conduct as visit to ensure the facility is safe for residents come back to the facility.

Staff did not ensure documents were not missing from resident's records.
It is the concern of the Reporting Party (RP) that on March 19, 2026, during the review of residents’ files, it was noted that R1’s records were missing required medical documentation, including TB records, lab results, and physical and dental exam records. As of 04/16/2026, these documents remain outstanding and cannot be located. To investigate the allegation, LPA Urena interviewed the Administrator about the missing records. The Administrator’s interview revealed that at the time of the annual inspection conducted, the file for one resident did not have the required documentation. Furthermore the Administrator stated that they had taken R1 to get their medical assessment, but once the medical assessment was completed the physician's office staff refused to give them a copy of the report because the Administrator is not the responsible person for R1. The Administrator reported that they have a doctor's appointment for R1 to get another medical assessment done. Based on the information obtained through interviews, the allegation that staff did not ensure that the required residents’ records were available at the time of the visit, is deemed Substituted at this time.

Staff did not safeguard resident's personal belongings.
It is the concern of the Reporting Party (RP) that it has been noted that R1’s personal clothing items are missing from their bedroom dresser. Prior documentation indicates that several clothing items were purchased for R1 by close friends of R1 and a relative of R1 upon R1’s move into the facility. The interviews with staff revealed that the resident was admitted to the facility with some new clothing items, however they don’t know how the items may have been lost. Furthermore, the staff reported that they send a change of clothing with the resident to the day program and are not sure if the extra change of clothing comes back with the resident to the facility. When asked if the clothes/or bag are labeled with the resident’s name, the staff stated that the clothes or bag are not labeled. Additionally, there is no system in place at the facility to ensure that at least one staff member greeting the resident back in the afternoons, ensures that the bag of clothes comes back to the facility with the resident.
Based on the information obtained through interviews, the allegation that staff did not safeguard the personal belongings of R1, is deemed Substantiated at this time.
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Sandra Urena
LICENSING EVALUATOR SIGNATURE:

DATE: 04/21/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 29-AS-20260416140351
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 197608319
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/21/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/21/2026
Section Cited
CCR
85072(a)(b)(6)
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In addition to Section 80072, the following shall apply.(b)The licensee shall insure that each client is accorded the following personal rights, (6)To possess and use his/her own personal items, including his/her own toilet articles. This requirement is not met as evidence.

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The Administrator will review and train staff on Residents Personal Rights and submit proof to CCLD Office by 05/08/2026.

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Based on observation, S1 did not comply with the sections cited above by having R1 wear disposable briefs, when the R1 is not incontinent, which poses a potential health and safety risk to persons in care.
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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.
SUPERVISOR'S NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Sandra Urena
LICENSING EVALUATOR SIGNATURE:

DATE: 04/21/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2026
LIC9099 (FAS) - (06/04)
Page: 5 of 5
Control Number 29-AS-20260416140351
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 197608319
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/21/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/21/2026
Section Cited
CCR
85068.1(a)(d)
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(a)The licensee shall develop, maintain, and implement admission procedures which shall meet the requirements specified in this section. (d) The facility shall obtain the medical assessment, performed as specified in Section 80069. This requirement is not met as evidenced by
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Administrator will have the medical assessment completed for R1 by May 1st, 2026, and will email the LPA the required documentaion.
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Based on record review the licensee did not comply with the section cited above as one residen'st file was observed to be missing a medical assessment which poses a potential health risk to clients in care.
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Type B
04/21/2026
Section Cited
ILS
82026(h)
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Safeguards for Cash Resources, Personal Property, and Valuables of Residents. Each licensee shall maintain accurate records of accounts of cash resources, personal property, and valuables entrusted to his/her
care, including….This requirement is not met as evidence.

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The Administrator will create a plan of action to ensure that personal and property valuables are documented right away upon arrival in the LIC 621 and signed by the resident or responsible party. The Administrator will email the LPA a filled LIC 621 for R1. Additionally the
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Based on record review, one resident’s file out of six did not have the LIC 621 filled out for R1, and Administrator didnot ensure personal items were not missplaced or lost, which poses a potential health risk to clients in care.
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Administratror will put in a place a system to ensure that staff will check residents personal valuables are returned after attending the day program/school. The plan of operation will be reviewed with and and will create a sign in sheet and will email the plan and signatures to the LPA by May 1, 2026.
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: Kasandra Lopez
LICENSING EVALUATOR NAME: Sandra Urena
LICENSING EVALUATOR SIGNATURE:

DATE: 04/21/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2026
LIC9099 (FAS) - (06/04)
Page: 4 of 5