197610044-9-21-2023-29-AS-CYEE-CVW227-20230921170016

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610044
Report Date: 09/21/2023
Date Signed: 09/21/2023 05:00:24 PM

Document Has Been Signed on 09/21/2023 05:00 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:	MARY'S CHATEAU		FACILITY NUMBER:	197610044
ADMINISTRATOR:	PETIKYAN, MARY		FACILITY TYPE:	740
ADDRESS:	13912 VALERIO STREET		TELEPHONE:	(323) 333-8105
CITY:	VAN NUYS	STATE: CA	ZIP CODE:	91405
CAPACITY:	6	CENSUS: 6	DATE:	09/21/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Mary Petikyan, Administrator		TIME COMPLETED:	05:10 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 and was let into the facility by Anahit Derdzyan, Staff. Staff contacted Mary Petikyan, Administrator via telephone and she arrived a little later to conduct the visit. The reason for today's visit was explained. The facility is a single storey family home consisting of a living room, dining room, kitchen, 4 bedrooms, 3 full bathrooms and a attached garage. The facility is fire cleared for 5 NON-AMBULATORY and 1 BEDRIDDEN resident. The following were observed on today's visit: the living room is furnished with 2 sofas, coffee table, television and side tables. the dining room has a table with 6 chairs and a little desk with a chair. the kitchen is equipped with a refrigerator, 2 ovens and a microwave. Food supplies were reviewed and there were sufficient perishable foods for 2 days and insufficient non-perishables for 7 days. Facility also has 2 containers of emergency rations. Cleaning solutions are stored in a locked cabinet under the kitchen sink and in the locked linen closet Bedroom #1 was observed with 2 hospital beds, 2 night stands, 2 chairs, 2 lamps, 2 portable closets and no dressers. Room has a direct exit to the left side of the house Bedroom #2 was observed with 1 hospital bed, 1 night stand, 1 lamp, 1 chair, a closet and a dresser. Located in the room is a bathroom equipped with a sink, a shower and a toilet. Grab bars and a non-skid mat was observed. Water temperature was tested and read 115.7 degrees Fahrenheit. Bedroom #3 was observed with a hospital bed, a night stand, a chair, a lamp and a closet. There were no dressers. Bedroom #4 was observed with 2 hospital beds, 2 night stands, 2 lamps, 2 chairs, a built-in closet and

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Christine Yee	TELEPHONE: (747) 230-3890
LICENSING EVALUATOR SIGNATURE:	DATE: 09/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2023

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 09/21/2023 05:00 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: MARY'S CHATEAU	FACILITY NUMBER: 197610044
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/21/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87307(a)(3)(E)

Personal Accommodations and Services (a) Living accommodations and grounds shall be related to the facility's function. The facility shall be large enough to provide comfortable living accommodations and privacy for the residents, staff, and others who may reside in the facility. The following provisions shall apply: (3) Equipment and supplies necessary for personal care and maintenance of adequate hygiene practice shall be readily available to each resident. The resident may provide the following items; however, if the resident is unable or chooses not to provide them, the licensee shall assure provision of: (E) Portable or permanent closets and drawer space in the bedrooms for clothing and personal belongings. A minimum of eight (8) cubic feet (.743 cubic meters) of drawer space per resident shall be provided. 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 per tour of bedroom #1, #3, and #4 did not have a dresser, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/28/2023
	Plan of Correction
1 2 3 4	The Licensee will provide the residents in bedroom #1, bedroom #3 and bedroom #4 with a dresser that meets Title 2 requirements by 9/28/23

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 Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Christine Yee	TELEPHONE: (747) 230-3890
LICENSING EVALUATOR SIGNATURE:	DATE: 09/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2023

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: MARY'S CHATEAU	FACILITY NUMBER: 197610044
	VISIT DATE: 09/21/2023

NARRATIVE

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a portable closet. No dressers were observed. The bedroom is designated for bedridden use and has a French door that opens on to a ramp. Located in the room is also a bathroom with a shower stall, a toilet and a sink. Grab bars and non-skid mat was observed. Water temperature was tested and read 114.5 degrees Fahrenheit.
Located in the hallway is a laundry closet with a washer and dryer that were observed in use.
the common bathroom has a shower, toilet and a sink. Grab bars, a shower chair and a non-skid mat were observed. Water temperature was tested and read 117.5 degrees Fahrenheit.
The attached garage is primarily used for storage of diapers, water, food and extra furniture.
Extra linens were observed in the linen closet.
the facility has 2 fire extinguisher, both purchased on 7/18/23. One is located in the dining room and one by bedroom #1.
there are auditory devices on the outside exit doors and were operational
first aid kit was reviewed and contained band aid, gauze, tweezer, scissors, and thermometer. First aid manual was also observed.
The smoke/carbon monoxide combination detectors were tested and were operational.
The facility has a land line telephone and the facility number is (818)386-8160
The facility's liability insurance meets Title 22 requirements and is current.
Per tour of the backyard, a table with chairs, an umbrella and potted plants were observed. Both the front and backyard were clean.
Trash cans were observed on the street due to it being trash collection day.

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

Exit interview was conducted, APPEALS RIGHTS were discussed and a copy was given

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Christine Yee	TELEPHONE: (747) 230-3890
LICENSING EVALUATOR SIGNATURE:	DATE: 09/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2023

LIC809 (FAS) - (06/04)

Page: 3 of 4

Document Has Been Signed on 09/21/2023 05:00 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: MARY'S CHATEAU	FACILITY NUMBER: 197610044
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/21/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87555(b)(26)

87555 General Food Service Requirements (b) The following food service requirements shall apply (26) Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises. 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 per review of the food supply, there were insufficiient non-perishable foods observed in the pantry. A can of chicken, a couple cans of tuna, tomato sauces,a couple of peanut butter jars, ketchup, 16 boxes of pastas, 2 jars of jam, raisins, 3 canisters of oatmeal and boxes of jello, cereals were observed which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 09/22/2023
	Plan of Correction
1 2 3 4	Licensee will ensure that the facility maintains perishable foods for a minimun of 2 days and non-perishable foods for a minimum of 7 days on the premises at all times. Licensee purchased more non-perishables foods during the visit. (corrected at time of 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.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Christine Yee	TELEPHONE: (747) 230-3890
LICENSING EVALUATOR SIGNATURE:	DATE: 09/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2023

LIC809 (FAS) - (06/04)

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