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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610495
Report Date: 03/04/2025
Date Signed: 03/04/2025 05:08:10 PM

Document Has Been Signed on 03/04/2025 05:08 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:ROSSMOYNE HILLSFACILITY NUMBER:
197610495
ADMINISTRATOR/
DIRECTOR:		AVETISYAN, ARMINEFACILITY TYPE:
740
ADDRESS:1227 CAMPBELL STREETTELEPHONE:
(747) 338-8394
CITY:GLENDALESTATE: CAZIP CODE:
91207
CAPACITY: 6CENSUS: 0DATE:
03/04/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:20 AM
MET WITH:Armine AvetisyanTIME VISIT/
INSPECTION COMPLETED:
05:30 PM
NARRATIVE
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At approximately 10:20 a.m. on 03/04/25 Licensing Program Analyst (LPA) Nicholas Reed and Licensing Program Manager (LPM) Naira Margaryan conducted an unannounced case management visit.

Today's case management visit was conducted in conjunction with complaint investigation #31-AS-20250303144817 to issue previously identified deficiencies in the facility from a case management visit on 02/28/2025. LPA and LPM were unable to gain entry to the facility after several attempts. LPA called the administrator at 10:48 a.m. and disclosed the reason for the visit. The administrator stated their were no staff or clients at the facility today. The administrator’s representative joined the call and spoke for the administrator. The administrator’s representative stated they were unable to attend this visit at the current time and asked to reschedule the visit.

During Licensing visit conducted on 02/28/2025 the following deficiencies were observed by the LPAs Huma Rahimi and Nicholas Reed.

Fire Safety. Blocked and locked emergency exit. (Bedroom #2) The emergency exit was blocked with boxes and the doorknob was missing. The door was locked.

Fire clearance. Facility retained non-ambulatory resident R6. Fire clearance is approved to retain ambulatory residents only.

Criminal record clearance and association
Staff present in the facility without criminal record clearance or association to the facility.
2nd offense within 12 months.
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Nicholas Reed
LICENSING EVALUATOR SIGNATURE: DATE: 03/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/04/2025
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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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: ROSSMOYNE HILLS
FACILITY NUMBER: 197610495
VISIT DATE: 03/04/2025
NARRATIVE
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There was an insufficient number of competent staff to assist residents.
Staff working at the facility, Staff #3 (S3), indicated that they had no knowledge of the English Language to communicate. Incontinence care was not provided. Facility had strong odor of urine and other foul smell and residents’ pants were wet. Around 1:30pm, residents complained that they did not have lunch.

Alteration of existing facility sketch.
The bedroom #3 that was identified as a residents room was converted to the staff room and the the space adjacent to the living room separated with the doors, was used as a residents room and was marked as a room 1.

Medication assistance was not provided.
Residents did not receive their medication for about 3 days. Medication records were incomplete and at least 3 residents' medications were not refilled.

Residents’ files were missing/incomplete. Hospice and or home care records were not present or incomplete.
LPAs observed that at list 3 residents files are missing and other residents’ files were incomplete. Hospice/Home care records for residents either were missing or were incomplete.

False claims The Licensee rmisinformed the the Glendale Police Officer about Facility ownership and staff that was working at the facility.
Licensee accountability- Licensee claimed that he had no knowledge what transpired in the facility on 02/27/25 and that staff #1 (S1) does not work at the facility.
Medication assistance. Staff present at the facility had no knowledge how to provide medication assistance to facility residents.

All noted deficiencies were discussed on 02/28/25 between LPM Margaryan and the administrator. All deficiencies were cited and citations were recorded on the corresponding LIC809-D.
Civil penalties were issued for deficiencies posing immediate health and safety hazard to residents in care.
Exit interview conducted?? Appeal rights discussed? A copy of the report will be provided via email for signature.
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Nicholas Reed
LICENSING EVALUATOR SIGNATURE:

DATE: 03/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2025
LIC809 (FAS) - (06/04)
Page: 2 of 9
Document Has Been Signed on 03/04/2025 05:08 PM - It Cannot Be Edited


Created By: Nicholas Reed On 03/04/2025 at 03:07 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: ROSSMOYNE HILLS
FACILITY NUMBER: 197610495

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/04/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/05/2025
Section Cited
CCR
87202(a)(1)

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87202 Fire Clearance. (a) All facilities shall maintain a fire clearance... the licensee shall... obtain an appropriate fire clearance approved by … fire department (1) Non-ambulatory persons. This requirement was not met as evidenced by:
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The deficiency has been cleared at this time due to the facility having no staff or residents.
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Based on observations, interviews, and record review, the licensee did not comply with the section cited above in (01) resident, Resident #6, who was non-ambulatory which posed an immediate Health, Safety, or Personal Rights risk to persons in care.
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Type A
03/05/2025
Section Cited
CCR87355(e)(1)

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87355 Criminal Record Clearance
(e) All individuals ... shall prior to working... in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department.
This requirement was not met as evidenced by:
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The deficiency has been cleared at this time due to the facility having no staff or residents.
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Based on interviews and record review, the licensee did not comply with the section cited above by Staff #2 not having a criminal background clearance or association to the facility which posed 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.
SUPERVISOR'S NAME:Naira Margaryan
LICENSING EVALUATOR NAME:Nicholas Reed
LICENSING EVALUATOR SIGNATURE:
DATE: 03/04/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/04/2025


LIC809 (FAS) - (06/04)
Page: 3 of 9
Document Has Been Signed on 03/04/2025 05:08 PM - It Cannot Be Edited


Created By: Nicholas Reed On 03/04/2025 at 03:27 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: ROSSMOYNE HILLS
FACILITY NUMBER: 197610495

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/04/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/05/2025
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.
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The deficiency has been cleared at this time due to the facility having no staff or residents.
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Based on observations and interviews, the licensee did not comply with the section cited above in blocking the emergency exit door in Bedroom #2 with debris, which posed 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.
SUPERVISOR'S NAME:Naira Margaryan
LICENSING EVALUATOR NAME:Nicholas Reed
LICENSING EVALUATOR SIGNATURE:
DATE: 03/04/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/04/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/04/2025 05:08 PM - It Cannot Be Edited


Created By: Nicholas Reed On 03/04/2025 at 03:28 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: ROSSMOYNE HILLS
FACILITY NUMBER: 197610495

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/04/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/14/2025
Section Cited
CCR
87465(d)

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87465 Incidental Medical and Dental Care
(d) If the resident is unable to determine his/her own need for a prescription... facility staff designated by the licensee, shall be permitted to assist the resident with self-administration. This requirement was not met as evidenced by:
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The deficiency has been cleared at this time due to the facility having no staff or residents.
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Based on observations and interviews, the licensee did not comply with the section cited above by not assisting Resident #4 with their medications which posed a potential Health, Safety, or Personal Rights risk to persons in care.
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Type B
03/14/2025
Section Cited
CCR87465(h)(1)

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87465 Incidental Medical and Dental Care
(h) The following requirements shall apply… (1) Medications shall be centrally stored... (C)(2)…Centrally stored medicines shall be kept in a safe and locked place that is not accessible. This requirement was not met as evidenced by:
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The deficiency has been cleared at this time due to the facility having no staff or residents.
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Based on observations, the licensee did not comply with the section cited above by not locking the refrigerator or making the medications inside inaccessible to residents which posed 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:Naira Margaryan
LICENSING EVALUATOR NAME:Nicholas Reed
LICENSING EVALUATOR SIGNATURE:
DATE: 03/04/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/04/2025


LIC809 (FAS) - (06/04)
Page: 5 of 9
Document Has Been Signed on 03/04/2025 05:08 PM - It Cannot Be Edited


Created By: Nicholas Reed On 03/04/2025 at 03:36 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: ROSSMOYNE HILLS
FACILITY NUMBER: 197610495

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/04/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/14/2025
Section Cited
CCR
87411

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87411 Personnel Requirements – General Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs.
This requirement was not met as evidenced by:
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The deficiency has been cleared at this time due to the facility having no staff or residents.
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Based on observations and interviews, the licensee did not comply with the section cited above through demonstrated incompetence to care for residents on 02/28/2025 which posed a potential Health, Safety, or Personal Rights risk to persons in care.
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Type B
03/14/2025
Section Cited
CCR87305(a)

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87305 Alterations to Existing Building or New Facilities. (a) Prior to construction or alterations, all facilities shall obtain a building permit.
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The deficiency has been cleared at this time due to the facility having no staff or residents.
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Based on observations, interviews, and record review the licensee did not comply with the section cited above by altering the front area into a bedroom for residents without updating facility sketch, which posed 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:Naira Margaryan
LICENSING EVALUATOR NAME:Nicholas Reed
LICENSING EVALUATOR SIGNATURE:
DATE: 03/04/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/04/2025


LIC809 (FAS) - (06/04)
Page: 6 of 9
Document Has Been Signed on 03/04/2025 05:08 PM - It Cannot Be Edited


Created By: Nicholas Reed On 03/04/2025 at 04:38 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: ROSSMOYNE HILLS
FACILITY NUMBER: 197610495

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/04/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/14/2025
Section Cited
CCR
87456(a)(3)

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87456 Evaluation of Suitability for Admission. (a)Prior to accepting a resident for care... the facility shall, as specified in this article 8: (3) Obtain and evaluate a recent medical assessment. This requirement was not met as evidenced by:
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The deficiency has been cleared at this time due to the facility having no staff or residents.
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Based on interviews and record review, the licensee did not comply with the section cited above by not obtaining recent medical assessments for Resident #5 and Resident #6 which posed a potential Health, Safety, or Personal Rights risk to persons in care.
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Type B
03/14/2025
Section Cited
CCR87207

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87207 False Claims - No licensee, officer or employee of a licensee shall make or disseminate any false or misleading statement regarding the facility or any of the services provided by the facility. This requirement was not met as evidenced by:
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The deficiency has been cleared at this time due to the facility having no staff or residents.
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Based on interviews and observations, the licensee did not comply with the section cited above by misleading Glendale Police about facility ownership and staffing which posed 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:Naira Margaryan
LICENSING EVALUATOR NAME:Nicholas Reed
LICENSING EVALUATOR SIGNATURE:
DATE: 03/04/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/04/2025


LIC809 (FAS) - (06/04)
Page: 7 of 9
Document Has Been Signed on 03/04/2025 05:08 PM - It Cannot Be Edited


Created By: Nicholas Reed On 03/04/2025 at 04:44 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: ROSSMOYNE HILLS
FACILITY NUMBER: 197610495

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/04/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/14/2025
Section Cited
CCR
87506(a)

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87506 Resident Records. (a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff. This requirement was not met as evidenced by:
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The deficiency has been cleared at this time due to the facility having no staff or residents.
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Based on observations and record review, the licensee did not comply with the section cited above by not maintaining a complete facility file for Resident #5 and Resident #6 which posed a potential Health, Safety, or Personal Rights risk to persons in care.
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Type B
03/14/2025
Section Cited
CCR87506(b)(11)

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87506 Resident Records. (b) Each resident’s record shall contain at least the following information: (11) The documentation required by Section 87611 for residents with an allowable health condition. This requirement was not met as evidenced by:
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The deficiency has been cleared at this time due to the facility having no staff or residents.
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Based on observations and record review, the licensee did not comply with the section cited above by not maintaining medical documents for Resident #5 and Resident #6, which posed 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:Naira Margaryan
LICENSING EVALUATOR NAME:Nicholas Reed
LICENSING EVALUATOR SIGNATURE:
DATE: 03/04/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/04/2025


LIC809 (FAS) - (06/04)
Page: 8 of 9
Document Has Been Signed on 03/04/2025 05:08 PM - It Cannot Be Edited


Created By: Nicholas Reed On 03/04/2025 at 04:50 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: ROSSMOYNE HILLS
FACILITY NUMBER: 197610495

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/04/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/14/2025
Section Cited
CCR
87205(a)

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87205 Accountability of Licensee Governing Body. (a) The licensee, whether an individual or other entity, shall exercise general supervision over the affairs of the licensed facility. This requirement was not met as evidenced by:
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The deficiency has been cleared at this time due to the facility having no staff or residents
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Based on interviews and observations, the licensee did not comply with the section cited above by stating they were unaware of facility affairs on the night of 02/27/2025 which posed 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:Naira Margaryan
LICENSING EVALUATOR NAME:Nicholas Reed
LICENSING EVALUATOR SIGNATURE:
DATE: 03/04/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/04/2025


LIC809 (FAS) - (06/04)
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