<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609546
Report Date: 11/30/2023
Date Signed: 12/01/2023 07:58:24 AM


Document Has Been Signed on 12/01/2023 07:58 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:HMS HOMEFACILITY NUMBER:
197609546
ADMINISTRATOR:DAVTIAN, ZHANNAFACILITY TYPE:
740
ADDRESS:14650 RUNNYMEDE STTELEPHONE:
(818) 616-2345
CITY:VAN NUYSSTATE: CAZIP CODE:
91405
CAPACITY:6CENSUS: 6DATE:
11/30/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:38 AM
MET WITH:Zhanna Davtian, AdministratorTIME COMPLETED:
06:45 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Christine Yee conducted an unannounced required Annual Inspection using the complete CARE Inspection Tool and met with Zhanna Davtian, Administrator. The reason for today's visit was explained.

The facility is a single storey family home consisting of a living room, a dining room, a kitchen, 4 resident bedrooms, 3 full bathrooms and a attached garage. Located along the left side of the home and directly behind the garage is a fenced in swimming pool. The home is fire cleared for 5 NON-AMBULATORY and 1 bedridden resident. Bedroom #3 is designated for bedridden use.

The following were observed on today's visit:
  • The living room has the appropriate sitting for 6 residents, a coffee table, a television and a side table. The fireplace has a wire screen. The sliding glass door is equipped with a auditory device (operational)
  • The dining room has a table with seating for 6 residents. The sliding glass door is equipped with a auditory device(operational)
  • The kitchen has a stove, 2 microwaves and a refrigerator. Sufficient perishable foods were observed in the refrigerator. Sharp knives are stored in a locked box and is kept in a kitchen drawer.
  • Adjacent to the kitchen is the laundry room with a washer and dryer. Detergents and cleaning supplies are stored in a locked cupboard.
  • The garage is accessed through the kitchen and is primarily used for storage of the 7 days of non-perishable foods, 24 gallons of water, facility files, centrally stored medications, and bathroom supplies.
  • Bedroom #2 and #4 both contain a twin bed, a chair, a night stand, a lamp and a closet. No dressers were observed.
  • Bedroom #1 and #3 both contain 2 twin bed, 2 chairs, 2 night stands, 2 lamps and 2 closets. No dressers were observed.
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Christine YeeTELEPHONE: (747) 230-3890
LICENSING EVALUATOR SIGNATURE:
DATE: 11/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/30/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 5


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: HMS HOME
FACILITY NUMBER: 197609546
VISIT DATE: 11/30/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
  • a private bathroom is located between bedroom #2 and #3. It contains 2 sinks, a toilet, a shower with a chair. Grab bars and non-skid mat were observed. Water was tested and read 120 degrees Fahrenheit. LPA Yee recommended that the water temperature to be adjusted slightly to ensure that the water temperature does not go beyond 120 degrees Fahrenheit.
  • the bathroom located adjacent to Bedroom #1 contains a shower with a chair, a toilet, grab bar, a non-skid mat and a sink. The water temperature was tested and read 117.1 degrees Fahrenheit.
  • the bathroom located adjacent to bedroom #4 contains a shower, sink, toilet, non-skid mat but no grab bars. Water temperature was tested and read 106.4 degrees Fahrenheit.
  • The hardwired smoke detectors and smoke/carbon monoxide combination detectors were tested and were operational.
  • the only fire extinguisher purchased on 2/11/23 is located by the front door.
  • Extra bed linens, towels, blankets, comforters and pillows were observed in the hallway closet.
  • First Aid kit contained the required tweezer, scissors and a common thermometer. First aid manual was also observed.
  • All staff have current first aid/CPR training.
  • Per tour of the physical plant, the outside areas and the pool were semi-clean due to the tree trimmers just trimming all the trees and the facility has not had the time to sweep up. The pool is secured with a 5 food rod iron fence. Per Administrator,replacement chairs and table been ordered for the backyard for outside activities.
  • Trash cans located in the front were tightly sealed.
  • Per review of facility files, the Licensee is the payee for Resident #6 and does not maintain a Surety bond.
  • Per review of facility files, the Licensee was not able to provide evidence of Liability insurance except to provide copy of a insurance quote. Per review of the quote, the quote is for the three facilities owned by the licensee. They all share the same limit of 1 million per incident for a total annual aggregate of 3 million. Each facility needs to obtain liability insurance with the required limits.


Deficiencies cited under California Code of Regulations, Title 22, Division 6, Chapter 8.

Exit interview was conducted, APPEALS RIGHTS were 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: 11/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2023
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 12/01/2023 07:58 AM - 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: HMS HOME
FACILITY NUMBER: 197609546

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/30/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.605
Other Provisions
On and after July 1, 2015, all residential care facilities for the elderly, except those facilities that are an integral part of a continuing care retirement community, shall maintain liability insurance covering injury to residents and guests in the amount of at least one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate, caused by the negligent acts or omissions to act of, or neglect by, the licensee or its employees.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above per review of facility files, the licensee does not have liability insurance with the required limits of $1million per incident and $3 million annual aggregate. Per licensee, she has liability insurance but the limits are shared by the 2 sister facilities which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/07/2023
Plan of Correction
1
2
3
4
Licensee will ensure that Liability insurance is purchased for all 3 facilities that she owns with its own limits of $1 million per incident and a total annual aggregate of $3million by the POC date. Licensee will provide the Department with evidence that the appropriate coverage has been obtained for all facilities she owns.
Type B
Section Cited
CCR
87303(a)
87303 Maintenance and Operation: (a) 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
1
2
3
4
Based on observation, the licensee did not comply with the section cited above per tour of the physical plant, it was observed that the screen doors for the sliding glass door located in the living room had holes by the door handle which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/07/2023
Plan of Correction
1
2
3
4
Licensee will ensure that all screen doors are maintained in good repair. Licensee agreed to repair the screen door and submit photograph(PDF) once the repair is completed by 12/7/23.
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: 11/30/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/30/2023
LIC809 (FAS) - (06/04)
Page: 3 of 5


Document Has Been Signed on 12/01/2023 07:58 AM - 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: HMS HOME
FACILITY NUMBER: 197609546

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/30/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87307(a)(3)(E)
87307 Personal Accommodations and Services
(a) Living accommodations and grounds shall be related to the facility's function. The facility shall be large enough to provide comfortable living accommodations and privacy for the residents, staff, and others who may reside in the facility. (3)Equipment and supplies necessary for personal care and maintenance of adequate hygiene practice shall be readily available to each resident. The resident may provide the following items; however, if the resident is unable or chooses not to provide them, the licensee shall assure provision of: (E)Portable or permanent closets and drawer space in the bedrooms for clothing and personal belongings. A minimum of eight (8) cubic feet (.743 cubic meters) of drawer space per resident shall be provided.


This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above per tour of the physical plant, all the residents have not been provided with the required sized dressers which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/12/2023
Plan of Correction
1
2
3
4
Licensee will purchase the regulation sized dresser for all the residents' rooms and submit evidence that the required dressers have been provided for resident use by 12/7/23

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: 11/30/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/30/2023
LIC809 (FAS) - (06/04)
Page: 4 of 5


Document Has Been Signed on 12/01/2023 07:58 AM - 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: HMS HOME
FACILITY NUMBER: 197609546

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/30/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87216(a)
87216 Bonding (a) Each licensee, other than a county, who is entrusted to safeguard resident cash resources, shall file or have on file with the licensing agency a copy of a bond issued by a surety company to the State of California as principal. (1) The amount of the bond shall be in accordance with the following schedule:
Total Safeguarded Per Month Bond Required: $750 or less -$1,000, $751 to $1,500.- $2,000, $1,501 to $2,500 - $3,000
Every further increment of $1,000 or fraction thereof shall require an additional $1,000 on the bond.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above per review of facility records, the Licensee is the payee for Resident #6 and has not obtained a surety bond in the appropriate limits which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/07/2023
Plan of Correction
1
2
3
4
Licensee will ensure that a surety bond is obtained in the appropriate amount to ensure that the residents cash resources and valuables handled by the LIcensee are protected. Provide the Department with evidence that a surety bond in the appropriate amounts have been obtained by 12/7/23
Type B
Section Cited
CCR
87303(e)(4)
87303 Maintenance and Operation(a) 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. e) Water supplies and plumbing fixtures shall be maintained as follows: (4) Grab bars shall be maintained for each toilet; bathtub and shower used by residents.


This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above per tour of the physical plant the bathroom located by Bedroom #4 does not have grab bars in the shower stall which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/07/2023
Plan of Correction
1
2
3
4
Licensee will ensure that all bathrooms in the facility is equipped with the required grab bars. Licensee will provide evidence that grab bars have been installed in the bathroom located by Bedroom #4 by 12/7/23
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: 11/30/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/30/2023
LIC809 (FAS) - (06/04)
Page: 5 of 5