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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609298
Report Date: 09/22/2023
Date Signed: 09/22/2023 07:43:17 PM


Document Has Been Signed on 09/22/2023 07:43 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:MOM AND DADS RETREAT INCFACILITY NUMBER:
197609298
ADMINISTRATOR:ARMENUI AMY ARZUMANYANFACILITY TYPE:
740
ADDRESS:15214 WYANDOTTE STREETTELEPHONE:
(818) 390-7012
CITY:VAN NUYSSTATE: CAZIP CODE:
91405
CAPACITY:6CENSUS: 5DATE:
09/22/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Armenui Arzumanyan, AdministratorTIME COMPLETED:
07:55 PM
NARRATIVE
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Licensing Program Analyst (LPA) Christine Yee conducted an unannounced required Annual Inspection using the complete CARE Inspection Tool and was let into the home by Tagui Gabriyelyan, Staff. Armenui Arzumanyan, Administrator was contacted by staff and she arrived at 10:07am to conduct the visit. The reason for today's visit was explained.

The facility is a single storey home located in the back of the property consisting of 2 separate buildings with separate addresses. The home consists of a living room, dining room, kitchen, a den, 5 bedrooms and 4 full bathrooms. The facility is fire cleared for 1 AMBULATORY resident in bedroom #1, 4 NON-AMBULATORY residents in Bedrooms #2 and #3 and 1 BEDRIDDEN resident in Bedroom #4.
The following were observed on today's visit:
  • the living room, dining room and den all have the appropriate seating and furnishings. The fire place located in the den is wood burning and is not used
  • the kitchen is observed with a oven, microwave, toaster oven and stove.
  • the only fire extinguisher is located inside the pantry located in the kitchen
  • food supply was reviewed and sufficient perishable foods for 2 days and non-perishable foods for 7 days were observed.
  • Bedrooms #1 has a bed, a chair, a dresser, a night stand, a lamp and a closet. Window blinds are broken.
  • Bedroom #2 has a chair, a dresser, a night stand, 1 closet and a lamp and no bed. Bed is in storage due to use of a hospice bed that was returned. Blinds are broken. Located inside the room is a full bathroom with a shower, toilet and a sink. Grab bars, shower chair and a non-skid mat was observed Water temperature was tested and read 114.5 degrees Fahrenheit.
  • Bedroom #3 has 2 beds, 2 chairs, a sofa, 2 night stands, 2 lamps, a walk-in closet, a table with 2 chairs and no dressers. The blinds on the windows and on the back door were broken. Located in the room is a bathroom with a jacuzzi tub, 2 sink vanity, a shower stall, a toilet and a bidet. Grab bars,
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Christine YeeTELEPHONE: (747) 230-3890
LICENSING EVALUATOR SIGNATURE:
DATE: 09/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/22/2023
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 09/22/2023 07:43 PM - It Cannot Be Edited

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: MOM AND DADS RETREAT INC
FACILITY NUMBER: 197609298

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/22/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87204(b)
Limitations -Capacity and Ambulatory Status
(b) Resident rooms approved for 24-hour care of ambulatory residents only shall not accommodate nonambulatory residents. Residents whose condition becomes nonambulatory shall not remain in rooms restricted to ambulatory residents.

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 as per tour of the physical plant, it was observed that Resident #2, who uses a wheelchair resides in bedroom #1, which is fired cleared for ambulatory use only, which poses an immediate health, safety or personal rights risk to persons in care. IMMEDIATE CIVIL PENALTIES WERE ASSESSED
POC Due Date: 09/23/2023
Plan of Correction
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The Licensee will provide a plan of action by 9/23/23 as to how the faclity will come into compliance regarding the placement of a non-ambulatory resident is a room not approved for use by non-ambulator residents.
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 HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Christine YeeTELEPHONE: (747) 230-3890
LICENSING EVALUATOR SIGNATURE:
DATE: 09/22/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/22/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/22/2023 07:43 PM - It Cannot Be Edited

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: MOM AND DADS RETREAT INC
FACILITY NUMBER: 197609298

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/22/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

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 as per tour of the facility, the back and front yard were observed to need general cleaning. Discarded wood, planters, commodes, brooms, mops, dryer, ladder need to be discarded or stored away. Weeds along the right side of the home need to be trimmed, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/29/2023
Plan of Correction
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The Licensee will ensure that the outside areas are kept cleaning and well maintained at all times. Licensee will conduct general cleaning and discard/store all unused items by 9/29/23
Type B
Section Cited
CCR
87303(e)(5)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (5) Non-skid mats or strips shall be used in all bathtubs and showers.

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 as per tour of the bathrooms, the bathroom located inside bedroom #3 was observed without a non-skid mat which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/29/2023
Plan of Correction
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The licensee will purchase a non-skid mat for the bathroom located in bedroom #3 by 9/29/23
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 HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Christine YeeTELEPHONE: (747) 230-3890
LICENSING EVALUATOR SIGNATURE:
DATE: 09/22/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/22/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/22/2023 07:43 PM - It Cannot Be Edited

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: MOM AND DADS RETREAT INC
FACILITY NUMBER: 197609298

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/22/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87307(d)(2)
Personal Accommodations and Services
(2) The premises shall be maintained in a state of good repair and shall provide a safe and healthful environment.

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 tour of the bedrooms, it was observed that all the residents bedroom window blinds and the door blinds in bedroom #3 were all broken and in disrepair which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/29/2023
Plan of Correction
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Licensee will inspect all facility windows and doors that have blinds to ensure that they are in good repair and take steps to replace all blinds that are broken and is disrepair.
Type B
Section Cited
CCR
87465(d)(2)
Incidental Medical and Dental Care Services
(d) If the resident is unable to determine his/her own need for a prescription or nonprescription PRN medication, and is unable to communicate his/her symptoms clearly, facility staff designated by the licensee, shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (2) The date and time of each contact with the physician, and the physician's directions, shall be documented and maintained in the resident's facility record.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above per review of resident records, it was observed that the facility does not any PRN Authorization letters for any of the residents who are currently prescribed PRN medications. The facility also does not document any physician's instructions or the results of the dosage of medications given.which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/29/2023
Plan of Correction
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Licensee will contact the prescribing physician to obtain completed PRN Authorization letters for all residents prescribed PRN medication and provide a plan as to how the physician's instructions and result are going to be documented as well as the time the medication was given and the dosage given.
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 HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Christine YeeTELEPHONE: (747) 230-3890
LICENSING EVALUATOR SIGNATURE:
DATE: 09/22/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/22/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/22/2023 07:43 PM - It Cannot Be Edited

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: MOM AND DADS RETREAT INC
FACILITY NUMBER: 197609298

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/22/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87212(b)
Emergency Disaster Plan
(b) The plan shall be subject to review by the Department and shall include:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above as the Licensee was not able to provide a copy of the Emergency Disaster Plan to LPA Yee for review which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/29/2023
Plan of Correction
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Licensee will write up a Emergency Disaster Plan and submit to the Department for review. by 9/29/23
Type B
Section Cited
CCR
87633(h)(1)
Hospice Care for Terminally Ill Residents
(h) For each terminally ill resident receiving hospice services in the facility, the licensee shall maintain the following in the resident's record: (1) A written request for acceptance or admittance to or retention in the facility while receiving hospice services, along with any advance directive and/or request regarding resuscitative measures form executed by the resident or (in certain instances) the resident's Health Care Surrogate Decision Maker.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above per review of Resident #1's hospice file, there were no written request for acceptance or admittance to or retention in the facility while receiving hospice services observed in the residents file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/29/2023
Plan of Correction
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Licensee will obtain a written request for acceptance or admittance to or retention in the facility while receiving hospice services from Resident #1 and maintain in the Resident's file by 9/29/23
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 HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Christine YeeTELEPHONE: (747) 230-3890
LICENSING EVALUATOR SIGNATURE:
DATE: 09/22/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/22/2023
LIC809 (FAS) - (06/04)
Page: 5 of 6


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: MOM AND DADS RETREAT INC
FACILITY NUMBER: 197609298
VISIT DATE: 09/22/2023
NARRATIVE
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  • a shower chair and no non-skid mat were observed. Water temperature tested read 113.9 degrees Fahrenheit
  • Bedroom #4 has a bed, a chair, a night stand, a lamp, a dresser and a closet. The blinds are broken. Located inside the room is a full bathroom with a shower stall, a sink, and a toilet. Grab bars and non-skid mat was observed. Water temperature was tested and read 118.1 degrees Fahrenheit.
  • Bedroom #5 has a bed, a chair, a lamp, a night stand, and a portable closet. The blinds are broken
  • The common bathroom has a shower, a sink, a toilet. Grab bars and non-skid mat was observed. Water tested 115 degrees Fahrenheit.
  • First aid kit and first aid manual were observed and met Title 22 requirements.
  • The smoke/carbon monoxide combination detectors were tested at 3:57pm and were operational


Deficiencies cited under Californina Code of Regulations, Title 22, Division 6, Chapter 8. Immediate civil penalties were assessed.

Exit interview were conducted, APPEALS RIGHTS discussed and a copy was provided.
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Christine YeeTELEPHONE: (747) 230-3890
LICENSING EVALUATOR SIGNATURE:

DATE: 09/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2023
LIC809 (FAS) - (06/04)
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