197609546-12-12-2024-29-AS-EMOY-DBVTUR-20241212140246

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609546
Report Date: 12/12/2024
Date Signed: 12/12/2024 02:03:03 PM

Document Has Been Signed on 12/12/2024 02:03 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:	HMS HOME		FACILITY NUMBER:	197609546
ADMINISTRATOR/ DIRECTOR:	DAVTIAN, ZHANNA		FACILITY TYPE:	740
ADDRESS:	14650 RUNNYMEDE ST		TELEPHONE:	(818) 616-2345
CITY:	VAN NUYS	STATE: CA	ZIP CODE:	91405
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS: 6	DATE:	12/12/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:35 AM
MET WITH:	ZHANNA DAVTIAN- ADMINISTRATOR		TIME VISIT/ INSPECTION COMPLETED:	02:10 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) Erica Mosley arrived at the facility unannounced to conduct a required annual visit at 9:35 a.m. Upon arrival, LPA was greeted by staff and Administrator. LPA met with Administrator Zhanna Davtian and explained the reason for the visit. The LPA toured the physical plant areas inside and outside to ensure there are no health and safety hazards and the facility is in compliance with Title 22 Regulations. The facility is a single-story family home consisting of a living room, a dining room, a kitchen, 4 resident bedrooms, 3 full bathrooms and an attached garage. The home is fire cleared for 5 NON-AMBULATORY and 1 bedridden resident. Bedroom #3 is designated for bedridden use. KITCHEN: The LPA toured the kitchen/food service area at 9:40 a.m. The hot water was measured at 117.6 degrees Fahrenheit at 9:44 a.m. The kitchen appeared clean and the appliances and fixtures functional. Refrigerated and frozen foods were stored at proper temperature. There was a sufficient amount of two (2) day perishable and seven (7) day non-perishable food. Food labels were inspected and checked for dates and expiration dates. Food had labels clearly marked with dates. Knives and sharps were observed locked in a drawer. Cleaning supplies were stored in a locked cabinet in the laundry room adjacent to the kitchen locked and inaccessible. There were no pesticides or poisons observed near any food areas. (PAGE 1) (Report Continued on LIC 809-C PAGE 2...)

Kasandra Lopez	TELEPHONE: (818) 596-4343
Erica Mosley	TELEPHONE: (747) 230-3909
	DATE: 12/12/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2024

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 3

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: 12/12/2024

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

(PAGE 2)(Report Continued from LIC 809 PAGE 1...)

COMMON AREAS: The LPA inspected the living room and dining room area. The common areas were observed to be properly furnished and clean at the time of the visit. Furniture was observed to be in good condition. Fireplace was observed to be adequately screened at the time of the visit. The facility maintained a comfortable temperature. At 11:03 a.m., the smoke detector(s) and carbon monoxide detectors were tested and operational. Fire extinguishers were observed fully charged and purchased on 09/09/2024. The LPA observed required postings throughout the common spaces. The facility has a working telephone on premises. Auditory alarms on all doors were functional at the time of the visit. Entry/exits were free of obstruction. There is a washer and dryer on the premises. The last emergency disaster drill took place on 10/1/2024 and are conducted quarterly. Activities were observed in the common areas. An adequate supply of emergency food and water was observed in a hallway closet adjacent to the living room. LPA observed a sufficient supply of extra linens in a hallway closet. LPA observed a First Aid Kit located in the common room. The first aid supplies were complete, including a thermometer and a current version of a first aid manual.

OUTDOORS: There is a locked shed in the backyard with extra supplies. LPA observed a sufficient supply of Personal Protectant Equipment (PPE). The backyard has a shaded area with furniture including a table and chairs for resident use. The LPA observed one gate that self-latches with a clear passageway in case of an emergency. There were no bodies of water noted at the time of the visit.

BEDROOMS: There are two (2) shared and two (2) private resident bedrooms. The resident bedrooms were properly furnished with a bed, night stand, and sufficient lighting for each resident. The bedrooms had appropriate and adequate bedding and linens such as sheets, pillowcases, mattress pads, and blankets.

(Report Continued on LIC 809C PAGE 3...)

SUPERVISOR'S NAME: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Erica Mosley	TELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:	DATE: 12/12/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2024

LIC809 (FAS) - (06/04)

Page: 2 of 3

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: 12/12/2024

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

(PAGE 3)(Report Continued from LIC 809-C PAGE 2...)
BATHROOMS: There are three (3) full bathrooms for resident use of which one (1) is designated as a private resident bathroom. Resident bathrooms were clean, sanitary and in operating condition with grab bars and non-slip surfaces. The hot water was measured from approx. 9:50 a.m. – 10:02 a.m. and measured between 117.6 - 118.7 degrees Fahrenheit all within the required range.

RECORDS: Records review began at 10:05 a.m., six (6) resident records were reviewed for, but not limited to: appraisals, medical records, admissions agreement, consent forms. All files were in order at this time. Four (4) Personnel records including the Administrator’s file were reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All files were in order. The LPA and staff reviewed P&I Money at 12:00 p.m. for (1) resident who has their cash resources safe guarded by the facility. Cash resources were found to be separate and intact and not commingled with facility funds or petty cash.

MEDICATIONS: Medications review for six (6) residents began at approximately 12:08 p.m. Medications are centrally stored in a locked filing cabinet located in a hallway closet adjacent to room #3 and are inaccessible to residents in care. All medications including PRNs were labeled, stored, and locked inaccessible to residents. PRNs have physicians order on file. Medications are labeled and checked for expiration dates. No medication errors observed at this time.

INTERVIEWS:
From 12:20 p.m. – 12:45 p.m. LPA interviewed two (2) staff, and two (2) residents during the inspection. Staff were knowledgeable in resident rights, different forms of abuse and reporting procedures. Residents expressed no concerns at the time of the visit.

During today’s visit, the LPA obtained copies of the following: LIC 500 Personnel Report, LIC 9020 Resident Roster, Current liability insurance, and a Surety bond.

No deficiencies cited at this time. Exit interview conducted. A copy of the report was provided.

SUPERVISOR'S NAME: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Erica Mosley	TELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:	DATE: 12/12/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2024

LIC809 (FAS) - (06/04)

Page: 3 of 3