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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609006
Report Date: 02/16/2024
Date Signed: 02/16/2024 04:29:28 PM

Document Has Been Signed on 02/16/2024 04:29 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:VICTORY PLACE HOMEFACILITY NUMBER:
197609006
ADMINISTRATOR:AKHPARIAN, ANDREWFACILITY TYPE:
735
ADDRESS:6353 BABCOCK AVETELEPHONE:
(818) 585-0095
CITY:NORTH HOLLYWOODSTATE: CAZIP CODE:
91606
CAPACITY: 4CENSUS: 4DATE:
02/16/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Andrew Akhparian, AdministratorTIME COMPLETED:
04:35 PM
NARRATIVE
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Licensing Program Analyst (LPA) Christine Yee conducted a subsequent unannounced required Annual Inspection and continued to use the complete Care Inspection Tool during the visit. LPA Yee met with Andrew Akhparian, Administrator. Also present during the visit was Diana Gevorgyan, Staff.

The following domains were reviewed on today's visit: Infection Control, Operational Requirement, Staffing, Personnel Records- Training, Clients Rights-Information, Food Service and Client Records-Incident Reports.

On today's visit, LPA Yee reviewed all 4 resident files and 2 staff files, the Infection Control Plan, Emergency Disaster Preparedness Plan and Plan of Operations. LPA Yee also reviewed the perishable food supply stored in the kitchen refrigerator and the non-perishable food supply stored in the kitchen cupboards.

The following deficiencies were noted during the review of the above domains:
  • sufficient perishable foods for a minimum of 2 days were observed
  • insufficient non-perishable foods for a minimum of 7 days were observed. The Administrator was able to purchase additional non-perishable foods during today's visit.



Deficiencies cited under California Code of Regulations, Title 22, Division 6, Chapter 6. Any deficiencies not addressed on today's visit will be addressed on a return visit.

Exit interview was conducted, APPEALS RIGHTS discussed and a copy was given.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Christine Yee
LICENSING EVALUATOR SIGNATURE: DATE: 02/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/16/2024
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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Document Has Been Signed on 02/16/2024 04:29 PM - It Cannot Be Edited


Created By: Christine Yee On 02/16/2024 at 03:31 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: VICTORY PLACE HOME
FACILITY NUMBER: 197609006

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/16/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
85076(d)(1)
Food Service
(1) Supplies of staple nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days shall be maintained on the premises.

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 per review of the food supply, the facility had a few cans of roast beef, tuna, green beans, 5lb rice, macaroni and cheese, black beans, corn, a couple of cans of soup, 2 containers of Quaker oats that are not sufficient to last 7 days, which poses an immediate health, safety or personal rights risk to persons in care. Per staff, marketing day is tomorrow (2/17/24)
POC Due Date: 02/17/2024
Plan of Correction
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The Licensee will ensure that there is a minimum supply of perishable foods for 2 days and a minimum supply of non-perishable foods for 7 days maintained on the premises at all time.
***************the deficiency was corrected at the time of the visit. Additional non-perishable foods were purchased at the time of this visit.********
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.
SUPERVISOR'S NAME:Kristin Heffernan
LICENSING EVALUATOR NAME:Christine Yee
LICENSING EVALUATOR SIGNATURE:
DATE: 02/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/16/2024


LIC809 (FAS) - (06/04)
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