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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609298
Report Date: 02/29/2024
Date Signed: 02/29/2024 10:29:25 AM


Document Has Been Signed on 02/29/2024 10:29 AM - 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:
02/29/2024
TYPE OF VISIT:Case Management - OtherANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Amy Arzumanyan, AdministratorTIME COMPLETED:
10:40 AM
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Licensing Program Analyst (LPA) Christine Yee conducted an announced case management visit to inspect bedroom #1 that was altered to allow for the retention of a non-ambulatory resident in that room. Bedroom #1 was previously fire cleared for an ambulatory resident only. City permits were obtained for the alteration of bedroom #1 and fire cleared on 1/22/2024. The facility is now fire cleared for 5 NON-AMBULATORY residents and 1 BEDRIDDEN resident. Bedroom #3 is designated for use by bedridden resident.

On today's visit, LPA Yee conducted a tour of the entire facility, inside and outside, with emphasis on Bedroom #1 and Bedroom #3 to ensure that there aren't any obvious visible safety issues. The entrance to Bedroom #1 was altered to include a 20 minute fire rated door and a door that leads directly to the outside. The hallway leading to Bedrooms #2 through to Bedroom #5 also has a 20 minute fire rated door that was previously installed when the facility was licensed to allow residents in those bedroom time to exit from Bedroom #3.

Per today's inspection, LPA Yee did not observe any obvious safety issues with the facility and any issues that would prevent Bedroom #1 from being approved for use by a non-ambulatory resident. Effective as of today's visit, bedroom #1 is cleared for resident use.

Exit interview was conducted a copy of this report was provided.
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Christine YeeTELEPHONE: (747) 230-3890
LICENSING EVALUATOR SIGNATURE:
DATE: 02/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/29/2024
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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