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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610323
Report Date: 04/24/2025
Date Signed: 05/05/2025 01:51:01 PM

Document Has Been Signed on 05/05/2025 01:51 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 S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:CARING LOVE BOARDING CAREFACILITY NUMBER:
197610323
ADMINISTRATOR/
DIRECTOR:		KIM HOVHANNISYANFACILITY TYPE:
740
ADDRESS:5902 SHIRLEY AVETELEPHONE:
(818) 793-4777
CITY:TARZANASTATE: CAZIP CODE:
91356
CAPACITY: 6CENSUS: DATE:
04/24/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Kim HovhannisyanTIME VISIT/
INSPECTION COMPLETED:
01:15 PM
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At approximately 9:30 a.m. on 04/24/2025, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced annual inspection. LPA met with staff and later the administrator and disclosed the reason for the visit.

A file review was conducted prior to today’s visit.

The facility was last visited on 07/26/2023 for a prelicensing visit. It is a single story building with three (03) bedrooms, two (02) bathrooms, kitchen, laundry area, common areas, and outdoor areas. It has an approved fire clearance for two (02) ambulatory residents and four (04) nonambulatory residents, of which one (01) may be bedridden in Bedroom #3. Approved hospice waivers for six (06).

LPA observed a maintained front yard and an unlocked perimeter gate. A screening station at the front contained surgical masks, sanitizer, a digital thermometer, and a visitor log. Postings at the front and in the kitchen included the facility license, confidential complaints contacts, ombudsman contacts, emergency disaster plan, rights of resident councils, personal rights, weekly menu, activity schedule, theft and loss policy, house rules, and the facility sketch.

Walls, floors, windows, screens, and blinds were clean and in good repair. At 9:45 a.m. LPA measured the room temperature to be 72 degrees Fahrenheit. Two (02) residents were observed in the living room drinking tea. A fireplace was appropriately covered. Board games, art supplies, and a television were also provided in the living room.

NAME OF LICENSING PROGRAM MANAGER: Naira Margaryan
NAME OF LICENSING PROGRAM ANALYST: Nicholas Reed
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/24/2025
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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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 S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: CARING LOVE BOARDING CARE
FACILITY NUMBER: 197610323
VISIT DATE: 04/24/2025
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LPA observed an adequate supply of perishable and non-perishable foods in the kitchen. Emergency food and water supplies were stored in a pantry near the refrigerator. Appliances were in good condition. Sharps were locked under the counter top. At approximately 9:55 a.m. LPA observed a fully charged fire extinguisher in the kitchen. Medications were locked above the counter. The stove surface and hood were clean. LPA conducted a medication review at approximately 10:00 a.m. Three (03) out of three (03) resident medication quantities were maintained in the proper amount.

A washing machine and dryer were located in the laundry area outside of the kitchen. Both were in working order. Detergents and cleaning supplies were locked above the appliances. LPA observed a patio area in the rear of the facility. The patio contained furniture in good condition and an electric piano. Additional shaded seating was located in the back yard. The garage was locked and contained extra supplies.

The living room contained a television, reading material, exercise equipment, and furniture in good repair. A fireplace was appropriately covered and turned off. Medications were locked near the main entrance.

The facility has three (03) bedrooms. All bedrooms contained a chair, lamp, nightstand, storage, and a bed with adequate bedding. All furnishings were clean and in good condition. All rooms with hospital beds had wheels in the locked position. Bedroom #2 and Bedroom #3 contained beds with full bed rails. At 12:00 p.m. LPA verified that all residents with full bed rails had physician orders for bed rails in their files.

The facility has two (02) bathrooms. One (01) bathroom was private to Bedroom #1. All bathrooms contained liquid soap, paper towels, trash can with a tight fitting lid, grab bars near the toilet and shower, and a non-skid mat in the shower. At approximately 10:15 a.m. LPA measured the water temperature in Bathroom #1 to be 118.4 degrees Fahrenheit.

The administrator called the house telephone at 10:45 a.m. The phone was deemed operational. A complete first aid kit was stored near the kitchen. The emergency exit path was free from obstructions. Auditory alarms at the front and in Bedroom #1 and Bedroom #3 were turned on and functioning. At 12:25 p.m., smoke and carbon monoxide detectors were tested and operational. Detectors functioned simultaneously when tested.

At 11:10 a.m. LPA reviewed staff and resident files. All files were complete and available for audit.

During today's inspection, the facility was in compliance with Title 22 regulations. No immediate health or safety hazards were observed. Exit interview conducted. Copy of report provided.

NAME OF LICENSING PROGRAM MANAGER: Naira Margaryan
NAME OF LICENSING PROGRAM ANALYST: Nicholas Reed
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2025
LIC809 (FAS) - (06/04)
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