197609651-1-28-2025-29-AS-TBYE-DDCVCQ-20250128151930

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609651
Report Date: 01/28/2025
Date Signed: 01/28/2025 03:19:44 PM

COMPREHENSIVE INSPECTION

Document Has Been Signed on 01/28/2025 03:19 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:	VILLA CATHERINE SENIOR CARE FACILITY		FACILITY NUMBER:	197609651
ADMINISTRATOR/ DIRECTOR:	RUZANNA SUKIASSYAN		FACILITY TYPE:	740
ADDRESS:	7001 VAN NOORD AVE		TELEPHONE:	(818) 279-4309
CITY:	NORTH HOLLYWOOD	STATE: CA	ZIP CODE:	91605
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS: 0	DATE:	01/28/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	12:47 PM
MET WITH:	Ruzanna Sukiassyan		TIME VISIT/ INSPECTION COMPLETED:	03:30 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) Trevor Byrne arrived at the facility unannounced to conduct a required annual visit at 12:47 PM. LPA contacted the facility administrator Ruzanna Sukiassyan. The Administrator informed the LPA that the facility does not currently have any clients and no staff were located on site. The Administrator agreed to meet with LPA and arrived to the facility at 01:50 PM. Entrance interview conducted and the reason for the visit was explained. Beginning at 01:50 PM, the LPA, along with facility administrator toured the physical plant areas inside and outside to ensure there are no health and safety hazards and that facility is in compliance with Title 22 Regulations. The following was observed: KITCHEN: The LPA observed the kitchen area to be clean. Kitchen appliances appeared to be in operable condition. LPA observed a secured drawer to contain knives and other sharp objects. LPA observed a secured cabinets designated to contain resident medications and a first aid kit. LPA observed a camera covering the kitchen area. LPA confirmed with the facility administrator that audio is not recorded. LPA observed a fire extinguisher mounted in the kitchen to be fully charged and last serviced on 11/20/2023. COMMON AREAS: This includes the living room, hallway, and dining room. LPA observed the dining room to be clean and properly furnished at the time of the visit. The dining room contains a dining table with adequate seating for resident use. The living room was observed to be clean and in good repair. The living room contained adequate seating and activities for resident use. LPA observed an appropriately screened fireplace located in both the living room and dining room. The facility’s combination fire and carbon monoxide alarms, as well as the facility fire doors, were tested at 02:28 PM. LPA observed three (3) fire doors to fail to close at the time of the test. The doors were attached to bedroom #1, bedroom #2, and bedroom #3. LPA observed cameras located throughout the common areas of the facility. LPA observed all required postings located at the front entrance to the facility. Continued on LIC 809C.

Kasandra Lopez	TELEPHONE: (818) 596-4343
Trevor Byrne	TELEPHONE: 747-444-6104
	DATE: 01/28/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/28/2025

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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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: VILLA CATHERINE SENIOR CARE FACILITY	FACILITY NUMBER: 197609651
	VISIT DATE: 01/28/2025

NARRATIVE

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BEDROOMS: There are four (4) bedrooms in the facility; three (3) are dual occupancy rooms and one (1) is a single occupancy room. At the time of the inspection bedroom #4 is designated as the staff bedroom. LPA and facility administrator toured all four (4) bedrooms. All bedrooms were observed to be furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting. All bedrooms were observed to contain direct exits to the outside of the facility. Bedroom #1 and bedroom #2 were observed to contain beds blocking the emergency exits. At the time of the visit the Administrator and staff rearranged the bedrooms so both exits were clear from obstruction.

BATHROOMS: There are three (3) bathrooms at the facility. All three (3) bathrooms are designated as shared resident bathrooms. All resident bathrooms were observed to be clean and in good repair and were equipped with nonskid surfaces. Grab bars were observed in all resident showers and near all resident toilets, all were properly secured. The water temperature was measured between 113.2 and 119.3 degrees Fahrenheit, which is in compliance with regulation.

OUTDOOR SPACE: The facility has three (3) emergency exit gates located on the perimeter fence of the facility; LPA observed clear passageways for emergency exit use. The facility has adequate shaded seating outdoors for resident use. LPA observed a locked storage building to contain wheelchairs, emergency food and water supplies, facility maintenance supplies, and extra care supplies. An outdoor deck was observed to be connected to the living room and bedroom #1, bedroom #2, bedroom #3, and bedroom #4. All railings on the deck were properly secured. LPA observed cameras throughout the outdoor spaces of the facility. LPA observed an appropriately fenced off pool that was made inaccessible to potential clients in care. LPA observed a covered laundry area located on the side of the facility to contain a washer and dryer along with appropriate storage for cleaning chemicals. LPA observed a fountain at the front of the facility to be empty of water.

INFECTION CONTROL/EMERGENCY DISASTER PLANNING: During today’s visit, the LPA reviewed the
facility's infection control practices and the facility's emergency disaster plan. The facility’s policies and procedures as it pertains to infection control are adequate. The facility’s emergency disaster plan is up to date and is adequate. Both the infection control plan and the emergency disaster plan are reviewed/updated annually by the facility’s administrator.
Continued on LIC 809C.

SUPERVISOR'S NAME: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Trevor Byrne	TELEPHONE: 747-444-6104
LICENSING EVALUATOR SIGNATURE:	DATE: 01/28/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/28/2025

LIC809 (FAS) - (06/04)

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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: VILLA CATHERINE SENIOR CARE FACILITY	FACILITY NUMBER: 197609651
	VISIT DATE: 01/28/2025

NARRATIVE

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As no residents were residing at the facility at the time of the inspection file review, medication review, and interviews were not conducted during today’s inspection. During today’s visit LPA obtained a copy of the facility’s LIC 500, and liability insurance.

No deficiencies were observed during today’s inspection as no clients were in the care of the facility. Exit interview conducted and copy of the report was issued.

SUPERVISOR'S NAME: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Trevor Byrne	TELEPHONE: 747-444-6104
LICENSING EVALUATOR SIGNATURE:	DATE: 01/28/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/28/2025

LIC809 (FAS) - (06/04)

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