197609786-5-26-2026-29-AS-ABAN-DUFUMP-20260526154239

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609786
Report Date: 05/26/2026
Date Signed: 05/26/2026 03:43:29 PM

Document Has Been Signed on 05/26/2026 03:43 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		CENSUS: 5	DATE:	05/26/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	11:00 AM
MET WITH:	Serguei Kalistratov		TIME VISIT/ INSPECTION COMPLETED:	03:50 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) Angela Barutyan arrived at the facility unannounced to conduct a required annual visit at 11:00AM. Upon arrival, LPA met with staff and Administrator Serguei Kalistratov who arrived at 11:40AM. Entrance interview conducted. At 11:29AM, the LPA along with staff, toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. KITCHEN/GARAGE: The LPA inspected the kitchen/food service area at 11:29AM. Kitchen appliances appeared clean and were in operable condition at the time of the visit. The facility has a sufficient supply of perishable and nonperishable food. Food labels were inspected and checked for expiration dates and food labels had expiration date clearly marked. Knives were locked inaccessible in a kitchen drawer. Fire extinguisher was fully charged and last serviced 03/12/2026. The attached garage is kept locked and inaccessible and contains an additional refrigerator/freezer, laundry, nonperishable food, and supplies. BEDROOMS: There are six (6) private resident bedrooms. LPA observed resident bedrooms to be furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting. RESTROOMS: There are three (3) restrooms. Restrooms were clean and sanitary and in operating condition with grab bars and slip-resistant surfaces. Hot water temperatures were measured in client bathrooms and were between 105.1-108.1 degrees F, which is within the required range. Report Continued on LIC 809-C

NAME OF LICENSING PROGRAM MANAGER: Kristin Heffernan
NAME OF LICENSING PROGRAM ANALYST: Angela Barutyan
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/26/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2026

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 4

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)

Page: 2 of 4

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
	VISIT DATE: 05/26/2026

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

COMMON AREAS: At the time of the visit, living room and dining area furniture were observed to be in good condition. The facility maintained a comfortable temperature. At 11:51AM, smoke detector(s) and carbon monoxide detector were tested and were operational at the time of the visit. LPA observed required postings throughout the common spaces.
OUTDOOR AREA: LPA observed the back patio which has a covered area for resident use. There is a self-latching gate on the side of the house designated for an emergency exit. Passageways were free and clear from obstruction. There are no bodies of water on the premises.
MEDICATION REVIEW: At 11:54AM, LPA reviewed medications for two (2) residents. Medications are centrally stored and locked in a cabinet by the dining area. All medications including PRNs were labeled, stored, and locked inaccessible to residents. LPA observed the centrally stored medication and destruction records (CSMDRs) for two (2) residents that were missing medication quantity and had medications with start dates logged as future dates. LPA also observed weekly pill organizers being utilized instead of medications being stored in their originally received containers. LPA observed several medications from bubble packs that were popped out and taped back rather than destroyed. Quetiapine Fumarate 50mg 1 tab twice daily quantity of 30 for Resident #1 (R1) had a start date of 05/25/2026, however, only twelve (12) pills were observed during medication review on 05/26/2026 instead of twenty-seven (27). Administrator stated that there might have been an error in logging the start date. Administrator stated he will conduct medication training with all staff and the facility will no longer utilize the pill organizers to prepare medications in advance; medications will be kept and administered from their bottles.
RECORD REVIEW: Beginning at 02:20PM, LPA reviewed five (5) out of five (5) resident files and four (4) personnel files for documents including but not limited to: medical records, care plans, health screening, staff training and fingerprint clearance. All resident and personnel files were in order.
INFECTION CONTROL/EMERGENCY DISASTER PLANNING: During today’s visit, the LPA reviewed the facility's infection control policy and emergency disaster plan. Emergency disaster plan is updated annually as required and emergency disaster drills are conducted quarterly as is required, with the last drill conducted on 04/12/2026. All documents reviewed were updated and in compliance.

The following deficiency was observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22. Administrator was informed that failure to correct deficiency may result in civil penalties.

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

NAME OF LICENSING PROGRAM MANAGER: Kristin Heffernan
NAME OF LICENSING PROGRAM ANALYST: Angela Barutyan
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/26/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2026

LIC809 (FAS) - (06/04)

Page: 3 of 4

Document Has Been Signed on 05/26/2026 03:43 PM - It Cannot Be Edited

Created By: Angela Barutyan On 05/26/2026 at 03:35 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: WOODLAND HILLS RETIREMENT HOME	FACILITY NUMBER: 197609786
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/26/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87465(h)(1)

(h) The following requirements shall apply to medications which are centrally stored: (1) Medications shall be centrally stored under the following circumstances: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on medication review, the licensee did not comply with the section cited as medications were not stored in their original containers, logs were missing medication quantities and had start dates for future dates, and Resident #1's medication had pill count discrepancies which poses a potential health and safety risk to persons in care.
	POC Due Date: 06/05/2026
	Plan of Correction
1 2 3 4	Administrator stated the facility will no longer utilize weekly pill organizers and will conduct medication training with all staff regarding medication administration, properly logging medications, and storing medications. Administrator will submit proof to CCLD by the due date.

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:

	Angela Barutyan
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/26/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2026

LIC809 (FAS) - (06/04)

Page: 4 of 4