197609778-7-21-2026-29-AS-CYEE-DW83P7-20260721182504

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609778
Report Date: 07/21/2026
Date Signed: 07/21/2026 06:25:34 PM

Document Has Been Signed on 07/21/2026 06:25 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:	YOUR HOME ASSISTED LIVING		FACILITY NUMBER:	197609778
ADMINISTRATOR/ DIRECTOR:	AVETISYAN, ARMENUHI		FACILITY TYPE:	740
ADDRESS:	7022 MATILIJA AVENUE		TELEPHONE:	(818) 983-2224
CITY:	VAN NUYS	STATE: CA	ZIP CODE:	91405
CAPACITY: 6		CENSUS: 3	DATE:	07/21/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	10:16 AM
MET WITH:	Armenuhi Avetisyan, Administrator		TIME VISIT/ INSPECTION COMPLETED:	06:35 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. LPA Yee was let into the home by Charity Chisale, Staff. Armenuhi Avetisyan, Administrator was contacted by telephone and she arrived at 10:41am to conduct the visit. The facility is a single storey home consisting of a living room, dining room, kitchen, 3 resident bedrooms, 2 common bathrooms of which one is designated for staff use, a staff room and a attached garage. The home is fire cleared for 5 non-ambulatory and 1 bedridden. Bedroom #3 is approved for bedridden use. On today's visit, LPA Yee reviewed all 12 domains of the CARE Inspection Tool, 3 residents and 6 staff files and toured the physical plant, inside and outside and the following was observed: the living room, dining room and kitchen were furnished and equipped with the appropriate furniture for its designated use. The fireplace was observed with a fire screen. Bedroom #1, located in the front of the home is currently used as a private room and was observed with a hospital bed equipped with half bed rails and no written physician's order was observed to indicate the need for the bed rails, 2 night stands, 2 lamps, a chair and a built in closet. No dresser was provided at the request of the resident. The bed linens were provided as per the resident's personal request. Bedroom #2 located adjacent to the attached garage was observed with 2 hospital beds, The left bed was observed with a full bed rail and the empty bed was equipped with a half bed rail. No written Continued on LIC809-C

Kristin Heffernan
Christine Yee
	DATE: 07/21/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2026

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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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: YOUR HOME ASSISTED LIVING	FACILITY NUMBER: 197609778
	VISIT DATE: 07/21/2026

NARRATIVE

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physicians order was observed to indicate the need for the full and the half bed rail. Resident #2 is not on hospice. 2 night stands, 2 lamps, a chair and a built in closet was observed. Per the Administrator no dressers were provided at the request of the family. One of the beds in the room was vacant and the other bed had linens as personally requested by the resident-no flat sheets or comforters.
Bedroom #3 had 2 hospital beds 2 night stands, 2 lamps, 1 chair, no dressers were provided at the request of the residents. Both beds were equipped with a half bed rail and again there were no written physician's order indicating the need of the bed rails on file. A mattress cover, a fitted sheet and a blanket was observed. Flat sheet and comforter not observed on the beds as requested by the residents. Curtains need to be placed on the back window for privacy. The sliding glass door was equipped with an auditory device was not operational and replaced during the visit. The Licensee will rearrange the room to ensure that the beds are not blocking egress from the room in an emergency.
Flat sheets, blankets, bath towels and extra fitted sheets were observed in the linen closet located in the hallway.
The common bathroom, located by bedroom #2 was observed with a walk in shower, a toilet and a 2 sink vanity. Grab bars, a shower chair and a slip resistant mat was observed. The water temperature could not be tested during the visit as LPA Yee's thermometer and the facility's thermometer were not operational during the visit. The Administrator will test the water and will provide evidence that the water temperature was tested and will self-certify that the water temperature tested was within range of 105-120 degrees Fahrenheit by 7/22/27.
The bathroom by the front door is equipped with a large jacuzzi tub, a walk in shower, a sink and a toilet is designated for staff use.
The room located by the dining room, furnished with 2 beds is designated as an office and for staff use.
The facility has 2 fire extinguishers. One is located in the living room and was purchased on 3/23/26 and the one located in the dining room was purchased on 1/7/26.
The auditory device located on the outside exiting front door and the backsliding glass door were turned off were operational when tested. The auditory device located on the sliding glass door in bedroom #3 was not operational and was replaced during the visit.

Continued on LIC809-C

NAME OF LICENSING PROGRAM MANAGER: Kristin Heffernan
NAME OF LICENSING PROGRAM ANALYST: Christine Yee
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 07/21/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2026

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: YOUR HOME ASSISTED LIVING	FACILITY NUMBER: 197609778
	VISIT DATE: 07/21/2026

NARRATIVE

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The smoke detectors located in the resident rooms and the combination smoke/carbon monoxide detectors located in the resident hallway and the living room were tested and were operational.
The facility had the required first aid manual and first aid kit containing the required tweezer, scissors, thermometer and dressings.
Sufficient perishables food for a minimum of 2 days and non-perishable foods for a minimum of 7 days were observed on the premises and brought in during the visit. The required foods must be maintained on the premises at all times.
The facility has current general liability insurance for the required limits.
Per tour of the attached garage, a washer and dryer was observed and cleaning solutions were observed. The garage is primarily used for storage.
Located in the backyard is a covered patio furnished with a table and chairs.
The grass in the front and backyard needs mowing. The facility is currently having issues with their gardeners.
Trash cans located in front of the facility were observed to be tightly sealed.

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

Exit interview was conducted, APPEALS RIGHTS discussed and a copy was provided.

NAME OF LICENSING PROGRAM MANAGER: Kristin Heffernan
NAME OF LICENSING PROGRAM ANALYST: Christine Yee
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 07/21/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2026

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 07/21/2026 06:25 PM - It Cannot Be Edited

Created By: Christine Yee On 07/21/2026 at 05:05 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: YOUR HOME ASSISTED LIVING	FACILITY NUMBER: 197609778
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/21/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87307(a)(3)(B)

Personal Accommodations and Services

(B) Bedroom furniture, which shall include, for each resident, a chair, night stand, a lamp, or lights sufficient for reading, and a chest of drawers. 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 as there were no chest of drawers provided for residents use which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/28/2026
	Plan of Correction
1 2 3 4	The Licensee will ensure that the required Title 22 furniture is provided to each resident. A chest of drawers meeting the minimum requirement of 8 cubic feet will be provided to each resident for their use or obtain refusal letters from the residents and families and maintain in their file. Provide and evidence is provided to the Department by 7/28/26

Type B

Section Cited

CCR

87468(c)(1)

Personal Rights of Residents

(c) Licensees shall prominently post personal rights, nondiscrimination notice, and complaint information in areas accessible to residents, representatives, and the public. (1) The personal rights of residents specified in Sections 87468.1, Personal Rights of Residents in All Facilities and 87468.2, Additional Personal Rights of Residents in Privately Operated Facilities shall be posted as applicable to the facility. 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 as there were was no Additional Personal Right of Residents in Privately Operated Facilties posted which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/28/2026
	Plan of Correction
1 2 3 4	Licensee shall ensure that all the required positings are posted in a conspicuous and public area and available by for viewing and evidence provided to the Department by 7/28/26.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Kristin Heffernan
NAME OF LICENSING PROGRAM MANAGER:

	Christine Yee
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/21/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2026

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 07/21/2026 06:25 PM - It Cannot Be Edited

Created By: Christine Yee On 07/21/2026 at 05:05 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: YOUR HOME ASSISTED LIVING	FACILITY NUMBER: 197609778
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/21/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87608(a)(3)

Postural Supports

(a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions: (3) A written order from a physician indicating the need for the postural support shall be maintained in the resident's record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above as it was observed that 4 of the residents' beds are equipped with half bed rails and one resident bed is equipped with a full bedrail and there are no written physicians order indicating the need for the bed rails and Resident #3, with the full bed rail, which is prohibited, is also not on hospice which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/28/2026
	Plan of Correction
1 2 3 4	The Licensee will ensure that every resident who has a need for a half bedrail obtains a written physician's order indicating the need for the bedrails. Licensee will remove all bed rails or obtain a written physician's order indicating the need for the use of the half bedrails and maintain in the residents' file by 7/28/26.

Type B

Section Cited

CCR

87608(a)(5)(B)

Postural Supports

(B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above as Resident #3 bed was observed equipped with a full bed rail and the resident is not on hospice and there is no hospice care plan to warrant the use of the full bed rail and also does not have an exception in place to justify the use of a full bed rail, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/28/2026
	Plan of Correction
1 2 3 4	Licensee will ensure that residents who require the use of a full bed rail, which is prohibited, are on hospice and the need for the full bed rail is specified in the hospice care plan or have requested an exception from the Department. The Licensee will remove the full bedrail until an exception is granted by the Department. A written physician's order and documents and support letters from the doctor, family etc must be provided for consideration by 7/28/26

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Kristin Heffernan
NAME OF LICENSING PROGRAM MANAGER:

	Christine Yee
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/21/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2026

LIC809 (FAS) - (06/04)

Page: 6 of 7

Document Has Been Signed on 07/21/2026 06:25 PM - It Cannot Be Edited

Created By: Christine Yee On 07/21/2026 at 05:46 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: YOUR HOME ASSISTED LIVING	FACILITY NUMBER: 197609778
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/21/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87705(d)

87705 Care of Persons with Dementia (d) The licensee shall ensure that the facility has an auditory device or other staff alert feature to monitor exits on exterior doors and perimeter fence gates accessible to those residents who may be at risk for elopement, as defined in Section 87101, Definitions. 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 as it was observed that the auditory device mounted on the outside exiting door located in Bedroom #3 was not operational during the tour of the rooms which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/28/2026
	Plan of Correction
1 2 3 4	The Licensee will ensure that all auditory devices mounted on the outside exit doors - front door, back glass sliding door and the glass door in Bedroom #3 is inspected monthly to ensure that the auditory devices are operational so that staff monitor and are alerted to when those residents who may be at risk for elopement. *********the auditory device in bedroom #3 was replaced during the visit*********

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Kristin Heffernan
NAME OF LICENSING PROGRAM MANAGER:

	Christine Yee
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/21/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2026

LIC809 (FAS) - (06/04)

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