<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610495
Report Date: 07/01/2025
Date Signed: 07/01/2025 04:11:24 PM

Document Has Been Signed on 07/01/2025 04:11 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.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:ROSSMOYNE HILLSFACILITY NUMBER:
197610495
ADMINISTRATOR/
DIRECTOR:		ELENA KORDONSKIYFACILITY TYPE:
740
ADDRESS:1227 CAMPBELL STREETTELEPHONE:
(747) 338-8394
CITY:GLENDALESTATE: CAZIP CODE:
91207
CAPACITY: 6CENSUS: 0DATE:
07/01/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:45 AM
MET WITH:Administrator, Elena KordonskiyTIME VISIT/
INSPECTION COMPLETED:
04:20 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
At 9:45a.m., Licensing Program Analyst (LPA) Antonia Alvizar-Ettima conducted an unannounced Required One (1) year inspection to the facility. LPA was unable to gain entry to the facility after several attempts. LPA called the administrator at 10:05 a.m. and disclosed the reason for the visit. Administrator stated there were no staff or residents at the facility. Administrator arrived at approximately 10:35a.m. and granted LPA access to the facility.

At 11:00a.m., Administrator and LPA conducted physical plant tour inside and out. During the tour, LPA observed that the facility is a home located in a residential community. The front main door is the only entrance being utilized at the facility; it has a total of (04) bedrooms and two and half 2 ½ bathrooms. Three (03) shared bedrooms and one (01) and half (1/2) bathrooms are designated for residents. One (01) bedroom and one (01) bathroom are designated for live – in staff. Fire/Earthquake drill was last conducted on 01/02/2025. Required posting observed displayed in the facility office area (complaint hot line poster, personal rights, etc). Temperature of facility wall thermostat is observed and set to 76 Fahrenheit. The fire alarm/CO system was tested and observed to be working. No obstructions and or tripping hazards throughout the facility.

LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: Common Areas: These included the living room and dining area for residents. The common areas were properly furnished. Furniture in common area were observed to be in good repair. Fireplace in the living room was observed to be covered with protective metal gate and glass doors. Residents dining table fits six (06) residents.

(Continued to LIC 809-C)

NAME OF LICENSING PROGRAM MANAGER: Naira Margaryan
NAME OF LICENSING PROGRAM ANALYST: Antonia Alvizar-Ettima
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/01/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/01/2025
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 3
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 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: ROSSMOYNE HILLS
FACILITY NUMBER: 197610495
VISIT DATE: 07/01/2025
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
(Continued from LIC 809)

Bedrooms were toured and observed to be clean and properly furnished with appropriate dresser, beddings, and linens with sufficient lighting. Linen storage was also checked and observed to have ample supply of clean linen, comforters, and towels in facility. Bedrooms and kitchen/dining area has a smoke/CO detector that are functional. Bathrooms were observed to be clean, sanitary and with necessary supplies. The appropriate grab bars and mat in the shower. Hot water temperature measured at a range of 117.7°F to 118.9°F and within the required range. Resident’s personal hygiene supplied will be kept separate in their private room. Towels and washcloths are not shared. Kitchen Area is observed to be clean and sanitary. Sharps are locked and stored in a kitchen drawer. Toxins, cleaning solutions, and soap stored and locked under the kitchen sink. Laundry Area: LPA observed detergent, toxins and cleaning supplies locked an inaccessible to residents in kitchen cabinet. The washer and dryer machines appeared to be working and in good condition. Fire extinguisher was observed to be located between kitchen and dining area. Fire extinguisher were observed to be operable with purchased date 07/01/2025. Food: LPA observed at least two (02) days perishable and seven (07) days non-perishable food at the facility that is properly stored. Frozen foods are wrap and stored properly as well. Food storage and preparation areas are clean. Medication: At the time of this visit there were no medications. First aid kit was observed to be complete and locked in office area cabinet inaccessible to residents in care. Garage is detached from the house and observed to be locked and under construction. Administrator indicated the garage is currently being converted into an Accessory Dwelling Unit (ADU). Surrounding Grounds: The front grounds of the facility are well landscaped. All passageways and stairways were observed to be clear from obstruction. The outdoor area was enclosed, and there no body of water. Resident Records: There were no resident records to review at the time of this visit. Staff records were reviewed and observed the following: criminal record clearances, associated to this facility and cardiopulmonary resuscitation (CPR) and first aid were updated. Administrator's certificate was observed to be current.


There is no health and safety issue observed during this visit.

Exit interview conducted. A copy of this report issued.

NAME OF LICENSING PROGRAM MANAGER: Naira Margaryan
NAME OF LICENSING PROGRAM ANALYST: Antonia Alvizar-Ettima
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/01/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2025
LIC809 (FAS) - (06/04)
Page: 3 of 3