197609786-1-15-2025-29-AS-ABAN-DCXT2U-20250115132119

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609786
Report Date: 01/15/2025
Date Signed: 01/15/2025 01:21:37 PM

Document Has Been Signed on 01/15/2025 01:21 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:	WOODLAND HILLS RETIREMENT HOME		FACILITY NUMBER:	197609786
ADMINISTRATOR/ DIRECTOR:	KALISTRATOV, SERGUEI		FACILITY TYPE:	740
ADDRESS:	24301 OXNARD ST		TELEPHONE:	(818) 564-4381
CITY:	WOODLAND HILLS	STATE: CA	ZIP CODE:	91367
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS: 5	DATE:	01/15/2025
TYPE OF VISIT:	Case Management - Deficiencies	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	10:00 AM
MET WITH:	Serguei Kalistratov		TIME VISIT/ INSPECTION COMPLETED:	01:30 PM

NARRATIVE

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Licensing Program Analyst (LPA) Angela Barutyan conducted a Case Management - Deficiencies visit in conjunction with a complaint visit (Complaint Control #29-AS-20250113104134). The purpose of the visit is to issue a citation for a deficiency observed during the initial complaint investigation.

During the visit on 01/15/2025, LPA observed Staff #1 (S1) without a criminal record clearance. S1 stated to LPA that they are new and have been working at the facility for only one (1) day. However, Administrator Irina Fried stated that S1 began working at the facility a few weeks ago and is still in training. Per Administrator, S1 is a caregiver and also handles medications, therefore, S1 would need to obtain a criminal record clearance. LPA spoke with Licensee Serguei Kalistratov and Administrator at 12:45PM who stated that S1 began working and residing at the facility on 01/12/2025 when there were no residents residing at the facility due to evacuation orders on 01/09/2025 for the Palisades fire. However, per regulation, a criminal record clearance must be obtained prior to working or residing at the facility. Administrator stated that a livescan for S1 was submitted today and showed proof.

The following deficiency was observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22. Civil penalties were issued in the amount of $300. Failure to correct the deficiency may result in additional civil penalties.

Exit interview was conducted. A copy of the report and appeal rights were provided.

Kristin Heffernan	TELEPHONE: (818) 596-4493
Angela Barutyan	TELEPHONE: 747-922-1234
	DATE: 01/15/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/15/2025

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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Document Has Been Signed on 01/15/2025 01:21 PM - 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: WOODLAND HILLS RETIREMENT HOME	FACILITY NUMBER: 197609786
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/15/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

87355(e)(1) Criminal Record Clearance. Prior to working, residing or volunteering in a licensed facility, all individuals subject to a criminal record review shall obtain a clearance or criminal record exemption This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4
	POC Due Date: 01/16/2025
	Plan of Correction
1 2 3 4	Administrator stated that fingerprints were submitted today and S1 will be associated. Administrator will submit proof by 01/16/2025 to CCL.

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	TELEPHONE: (818) 596-4493
Angela Barutyan	TELEPHONE: 747-922-1234
	DATE: 01/15/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/15/2025

LIC809 (FAS) - (06/04)

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