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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197610495
Report Date: 02/28/2025
Date Signed: 02/28/2025 02:43:05 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/28/2025 and conducted by Evaluator Nicholas Reed
COMPLAINT CONTROL NUMBER: 31-AS-20250228100858
FACILITY NAME:ROSSMOYNE HILLSFACILITY NUMBER:
197610495
ADMINISTRATOR:AVETISYAN, ARMINEFACILITY TYPE:
740
ADDRESS:1227 CAMPBELL STREETTELEPHONE:
(747) 338-8394
CITY:GLENDALESTATE: CAZIP CODE:
91207
CAPACITY:6CENSUS: 6DATE:
02/28/2025
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Albert KhatchatryanTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Licensee is operating beyond the scope of their license
INVESTIGATION FINDINGS:
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At 10:00 a.m. on 02/28/25 Licensing Program Analysts (LPAs) Nicholas Reed and Huma Rahimi conducted an unannounced complaint visit. LPA met with the licensee and disclosed the reason for the visit.

To investigate the allegation above, LPAs toured the facility at 10:15 a.m. today, interviewed residents and staff between 10:30 a.m. and 12:45 p.m., and conducted a record review at 1:00 p.m. of pertinent records, including but not limited to an admission agreement, medical assessment, and care plan.
Regarding the allegation “Licensee is operating beyond the scope of their license” it was alleged that the facility had eight (08) residents in care as of 02/27/2025. LPAs observed six (06) residents in the home today. LPAs reviewed facility files of four (04) out of six (06) current residents. Two (02) residents did not have files which were available for audit. This deficiency is addressed on a corresponding LIC 809 page.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Nicholas Reed
LICENSING EVALUATOR SIGNATURE:

DATE: 02/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/28/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 4
Control Number 31-AS-20250228100858
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: ROSSMOYNE HILLS
FACILITY NUMBER: 197610495
VISIT DATE: 02/28/2025
NARRATIVE
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All four (04) resident files reviewed showed all residents have been admitted since or prior to 01/27/2025. Interview with the administrator confirmed that the facility provided care and supervision to at least seven (07) residents for the past week. The administrator stated Resident #8 (R8) returned from the hospital on the evening of 02/27/2025 but was removed from the facility within hours of returning. Based on interviews, record review, and observations, the facility provided care and supervision beyond their licensed capacity. Therefore, the allegation is deemed SUBSTANTIATED at this time. A deficiency is issued on the corresponding LIC 9099-D page.

Exit interview conducted. Appeal rights discussed. Copy of report provided.
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Nicholas Reed
LICENSING EVALUATOR SIGNATURE:

DATE: 02/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/28/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 31-AS-20250228100858
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: ROSSMOYNE HILLS
FACILITY NUMBER: 197610495
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/28/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/03/2025
Section Cited
CCR
87204(a)
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87204 Limitations - Capacity and Ambulatory Status (a) A licensee shall not operate a facility beyond the conditions and limitations specified on the license, including specification of the maximum number of persons who may receive services at any one time.
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As of today, the facility is within their capacity. The licensee has agreed to conduct and submit an in-service training by the POC due date.
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Based on interviews, record review, and observations, the licensee did not comply with the section cited above by having (08) residents in care which poses an immediate 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.
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Nicholas Reed
LICENSING EVALUATOR SIGNATURE:

DATE: 02/28/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/28/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 4