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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610588
Report Date: 04/10/2025
Date Signed: 04/10/2025 01:03:50 PM

Document Has Been Signed on 04/10/2025 01:03 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:CANOGA PARK DREAM HOUSEFACILITY NUMBER:
197610588
ADMINISTRATOR/
DIRECTOR:		DEMIRTSHYAN, YULYAFACILITY TYPE:
735
ADDRESS:8536 OWENSMOUTH AVETELEPHONE:
(818) 602-0220
CITY:CANOGA PARKSTATE: CAZIP CODE:
91304
CAPACITY: 4CENSUS: 0DATE:
04/10/2025
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:45 AM
MET WITH:Yulya Demirtshyan-AdministratorTIME VISIT/
INSPECTION COMPLETED:
01:00 PM
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On 4/10/2025 at 9:45am, Licensing Program Analyst (LPA) Perchui Milena Khurshudyan conducted an announced Pre-Licensing Inspection at the facility. Upon arrival LPA met with the Licensee/Administrator Demirtshyan Yulya, introduced herself showing the department badge and conducted an entrance interview.

This is a North Los Angeles Regional Center vendored facility and the licensee is planning to serve the client with intellectual disabilities at level three (3).

Fire Clearance was approved on 08/06/2024 for a maximum capacity of four (4) ambulatory clients. This is a single-story house with three (3) bedrooms and one and half (1.5) bathrooms. Bedrooms #1 and #2 designated for a capacity of four 4 clients, and bedroom #3 is designated for staff use only. Facility will have an awake night shift staff on premises. At 10:35am a physical plant was toured inside and out of the property with the assistance of the Licensee and the following was observed:

Kitchen Area: The kitchen is equipped with a refrigerator, microwave, oven, and sink. The facility has adequate supplies of two (2) days of perishable and seven (7) days of nonperishable food. LPA observed dining ware to accommodate a maximum capacity of four (4). The stove and the refrigerator were clean and in good operation. All knives and sharps are observed to be locked in a cabinet located in the kitchen area and inaccessible to clients. Chemicals are\will be kept in a locked cabinet under the sink. The facility has one (1) new fire extinguisher, appeared to be full and serviced and was last purchased on 04/08/2025.

BATHROOMS: The facility has one and half (1.5) bathrooms, both bathrooms are designated for the clients’ use. Both bathrooms were observed to have the proper fixtures, grab bars, and non-skid mats. The hot water delivered in the bathrooms measured at 10:45am to be at 110°F degrees.

Continue on LIC809-C

NAME OF LICENSING PROGRAM MANAGER: Nichelle Gillyard
NAME OF LICENSING PROGRAM ANALYST: Perchui Khurshudyan
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/10/2025
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)
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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.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: CANOGA PARK DREAM HOUSE
FACILITY NUMBER: 197610588
VISIT DATE: 04/10/2025
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Bedrooms: There are three (3) bedrooms in the facility of which two (2) are designated for clients’ use. Both bedrooms are set to be shared. All bedrooms are furnished and well equipped with bed, night stand, chair, dresser, bedding, pillowcase, mattress pad, and blankets, extra linen are available inside each bedroom. Rooms were observed to have sufficient lighting and closet space. LPA observed appropriate window screens. Sufficient supplies of personal hygiene products stored in the storage area will be provided to the clients by the Licensee. Facility will have an awake staff.

COMMON AREAS: At 10:45am LPA observed the living/family room and dining room furniture to be clean and in good repair. The facility maintains a comfortable temperature at 72°F. The air conditioner is operational. No firearms observed or will be maintained on the premises. Licensee has ordered puzzles, books, balls, and board games to provide activities to clients in care. No obstructions and or tripping hazards observed throughout the facility.

Laundry Area: The laundry room is located in the separate area next to the kitchen. The washer/dryer appear to be new and in good condition. Laundry supplies and other chemicals are kept locked in the laundry cabinet, inaccessible under supervision when not in use.

Medications: LPA observed medications along with first-aid kit will be kept centrally stored and locked inside the staff room and the key cannot be accessible to clients in use.

Clients and staff files will also be kept inside the staff room.

SMOKE DETECTORS/CARBON MONOXIDE. Smoke detectors and carbon monoxide were located throughout the facility. At 11:00am they were tested and observed to be operational. Facility has land-line which was checked at 11:05am to be operational.

SURROUNDING GROUNDS: The facility has sufficient yard space. LPA observed the backyard with appropriate outdoor furniture and covered shaded area for clients. LPA discussed the importance of maintaining the care and supervision to meet the needs of clients. There is no garage in the property. The side gate leading from the backyard to the front yard was not locked. LPA observed no pool or body of water.

Component III was conducted with the Licensee/Administrator.

Facility is in compliance with Title 22 Regulations at this time. This report will be forwarded to the Centralized Application Bureau (CAB) and will be notified by the CAB Analyst when the license has been approved.

Exit interview was conducted and a copy of this report was provided to the Applicant/Administrator.

NAME OF LICENSING PROGRAM MANAGER: Nichelle Gillyard
NAME OF LICENSING PROGRAM ANALYST: Perchui Khurshudyan
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2025
LIC809 (FAS) - (06/04)
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