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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609995
Report Date: 02/15/2024
Date Signed: 02/15/2024 01:21:58 PM


Document Has Been Signed on 02/15/2024 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:HEART OF HOME SENIOR LIVINGFACILITY NUMBER:
197609995
ADMINISTRATOR:MOVSESIAN, KAJOFACILITY TYPE:
740
ADDRESS:6425 NAGLE AVETELEPHONE:
(747) 247-2365
CITY:VAN NUYSSTATE: CAZIP CODE:
91401
CAPACITY:6CENSUS: 6DATE:
02/15/2024
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Kajo Movsesian, AdministratorTIME COMPLETED:
01:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Emily Peraldi conducted an unannounced case management - legal/non-compliance visit. At 9:28 a.m., the LPA met with staff and explained the reason for the visit. At 9:40 a.m., the Administrator Kajo Movsesian arrived at the facility. The purpose of today’s visit was to monitor the licensee’s compliance with Title 22 Regulations. The facility is on a two-year Compliance Plan. The LPA focused today’s visit on resident records and personnel records.

RECORD REVIEWS: Between 9:50 a.m. and 11:26 a.m., the LPA conducted a file review for all six (6) residents and staff regularly scheduled and observed the following: Staff have current first aid and training documentation showing required training completed. Resident records were reviewed for, but not limited to, care plans, medical records, admissions agreement, consent forms. It was noted that a disaster drill was conducted on 01/08/2024 and fire drill was conducted on 01/12/2024. All files were in order. The Administrator’s certificate expired on 12/19/2023 and is in the process of renewing.

At 12:00 p.m., the LPA along with the Administrator, conducted a brief physical plant tour. At 12:01 p.m., the LPA observed two (2) fire extinguishers to be last serviced on 11/03/2022. During the time of the visit, the Administrator had the two (2) fire extinguishers serviced. The hot water temperature was measured in all bathrooms and was found in compliance between 105.3 and 106.8-degrees Fahrenheit.

Pursuant to Title 22 of the California Code of Regulations Division 6, Chapter 8 and California Health and Safety Code the following deficiency was cited (refer to LIC 809-D)

Exit interview conducted. A copy of the report and appeal rights were provided.
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Emily PeraldiTELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:
DATE: 02/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/15/2024
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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Document Has Been Signed on 02/15/2024 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: HEART OF HOME SENIOR LIVING
FACILITY NUMBER: 197609995

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/15/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/16/2024
Section Cited
CCR
87203

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87203 Fire Safety
All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. This requirement is not met as evidenced by:
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The Administrator had the two fire extinguishers serviced during the time of visit.
POC has been met.
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Based on observation, the Licensee did not comply with the section cited above as two fire extinguishers were observed to be not serviced within a year which poses a potential health, safety or personal rights risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Emily PeraldiTELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:
DATE: 02/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/15/2024
LIC809 (FAS) - (06/04)
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