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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609656
Report Date: 03/06/2024
Date Signed: 03/06/2024 05:14:35 PM


Document Has Been Signed on 03/06/2024 05:14 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:VAN NOORD MANORFACILITY NUMBER:
197609656
ADMINISTRATOR:MKRTCHIAN, VAHEFACILITY TYPE:
740
ADDRESS:6700 VAN NOORD AVETELEPHONE:
(818) 414-0005
CITY:VALLEY GLENSTATE: CAZIP CODE:
91606
CAPACITY:6CENSUS: 4DATE:
03/06/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:31 AM
MET WITH:Vahe Mkrtchian, AdministratorTIME COMPLETED:
05:20 PM
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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 , staff. Vahe Mkrtchian, Administrator was contacted by staff and he arrived a little later to conduct the visit. The reason for today's visit was provided.

The facility is a single storey family home consisting of a living room, dining room, kitchen, four bedrooms of which one is used for live-in staff, 2 full common bathrooms and a attached garage. Located in the backyard is a swimming pool fenced in by a 5 foot rod iron fence. The facility is fire cleared for 1 BEDRIDDEN and 5 NON-AMBULATORY residents. Bedroom #1 is currently designated for bedridden use. The facility is vendorized by the North Los Angeles Regional Center and is a Level 3 home.

On today's visit, all 12 domains of the CARE Inspection Tool was reviewed. Also reviewed were 4 resident files, 5 staff files and the facility inside and outside was toured beginning at 2:56pm.

The following was observed during the tour of the facility:
  • The living room, dining room and kitchen had the appropriate furnishings and kitchen equipment for the four clients.
  • Bedroom #1 is used as a double occupancy room and Bedroom #2 and Bedroom #3 are used as single occupancy. All 3 resident bedrooms have the required beds, chairs, night stand, lamps and closet. The required bed linens were observed. Blinds on the windows were observed.
  • Bedroom #4 is designated for live-in staff and was toured.
  • Both common bathrooms are equipped with a large walk-in shower, a toilet and a sink. Grab bars and non-skid mats were observed. The common bathroom located on the right side of the hallway
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Christine YeeTELEPHONE: (747) 230-3890
LICENSING EVALUATOR SIGNATURE:
DATE: 03/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/06/2024
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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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: VAN NOORD MANOR
FACILITY NUMBER: 197609656
VISIT DATE: 03/06/2024
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  • also contained a shower chair. The water temperature was tested in both bathrooms. The right bathroom water temperature read 119.5 degrees and the left bathroom water temperature read 119.7 degrees Fahrenheit.
  • The only fire extinguisher located in the kitchen was purchased on 4/24/23
  • The smoke/carbon monoxide combination detectors were tested and were operational
  • Sufficient perishable foods for a minimum of 2 days and non-perishable foods for a minimum of 7 days were observed maintained on the premises
  • Medications are stored in the locked hallway closet
  • Knives are stored in a locked kitchen drawer
  • Cleaning solutions and disinfectants are stored in a locked cabinet under the sink and in the locked hallway closet.
  • First Aid kit was reviewed and contained the required scissors, tweezers and thermometer.
  • First Aid manual was observed.
  • Night lights in the hallway was observed.
  • The auditory devices on the exit doors were tested and were operational
  • Required posters were observed in the dining room, hallway and facility license by the front door
  • The facility has Liability insurance that meets the required $1 million per occurrence and $3 million annual aggregate.
  • The facility telephone obtained today is (818)308-7899
  • Per tour of the backyard the swimming pool is fenced in with a locked gate, The covered patio is furnished with rattan sofa and 2 armchairs. Also located on the patio is a washing machine and dryer and was observed to be operational. The trash cans were tightly sealed. The backyard was observed to be clean
  • Per tour of the front yard, there is a ramp leading from the front door. Designated area for smoking was observed. The front yard was observed to be clean.
  • Per tour of the garage, it is primarily used for storage.


No deficiencies were cited on today's visit.

Exit interview was conducted and 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: 03/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/06/2024
LIC809 (FAS) - (06/04)
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