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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195850528
Report Date: 01/16/2025
Date Signed: 01/16/2025 06:47:03 PM

Document Has Been Signed on 01/16/2025 06:47 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 N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:GRACEFUL ADULT CAREFACILITY NUMBER:
195850528
ADMINISTRATOR/
DIRECTOR:		TOROSYAN, GAYANEFACILITY TYPE:
735
ADDRESS:7314 CANTALOUPE AVETELEPHONE:
(323) 449-0944
CITY:VAN NUYSSTATE: CAZIP CODE:
91405
CAPACITY: 6CENSUS: 0DATE:
01/16/2025
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:11 AM
MET WITH:Anna Armenyan, ApplicantTIME VISIT/
INSPECTION COMPLETED:
06:50 PM
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Licensing Program Analyst(LPA) Christine Yee conducted an announced Prelicensing and Component III visit to ensure that the home meets Title 22 requirements. LPA Yee met with Anna Armenyan, Applicant. The designated Administrator was not able join in on the visit.

The home is a single storey family home located behind another home located on the same lot. The home consists of a kitchen, dining room, living room, 3 bedrooms, 2 full bathrooms. The home is fire cleared for 5 non-ambulatory and 1 bedridden clients. Bedroom #1 is the designated room for bedridden use.

The following was observed on today's visit:
  • the living room was furnished with the appropriate furniture and seating for 6 clients. A locked cabinet used to centrally store medications and a linen cabinet was also observed in the living room.
  • the dining room was observed with a table and 6 chairs.
  • The kitchen is equipped with a stove, refrigerator, toaster and microwave. 8 each of dinner and salad plates, coffee cups, water cups, soup bowels were observed to be sufficient for 6 clients. 8 of each, dinner forks, dessert forks, teaspoons, spoons and dinner knives were observed. Pots and pans were observed for cooking. Sufficient non-perishable foods for a minimum of 7 days were observed at the the end of this visit. Additional non-perishable foods were ordered and delivered during this visit. Some perishable foods, such as chicken, pork, beef , chicken wings were observed in the freezer. Vegetables, milk and other perishable foods for a minimum of 2 days will be purchased prior to accepting the first client. Knives are stored in a locked kitchen drawer. Cleaning solutions and laundry detergent are locked in a metal cabinet outside.
  • Located in the kitchen is the only fire extinguisher purchased on 1/15/25.
  • Bedroom #1 (closest to the living room)was not furnished and no extra furniture was observed in storage.
  • Bedroom #2 was furnished with 2 twin beds, 2 chairs, 2 portable closet, 2 dressers, 2 lamps and a dresser used as a night stand between the beds. Windows had curtains for privacy. The beds had the
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Christine Yee
LICENSING EVALUATOR SIGNATURE: DATE: 01/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/16/2025
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
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: GRACEFUL ADULT CARE
FACILITY NUMBER: 195850528
VISIT DATE: 01/16/2025
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  • required bed linens except there were no blankets. Throw blankets were observed.
  • Bedroom #3 has 2 twin beds, 2 chairs, 2 portable closets, a shared 6 drawer dresser, 2 lamps and 2 night stands. Window dressings for privacy were observed on the window. No blankets were observed.
  • Bath towels, hand towels, face towels and extra bed linens were observed in a cupboard in the living room.
  • located between bedroom #1 and bedroom #2 is the laundry closet that houses the stacked washer and dryer.
  • Hygiene products for the 6 clients were observed in the bottom cabinet under the centrally stored medications.
  • Both common bathrooms were observed equipped with a shower, a single sink vanity and a toilet. Grab bars were observed in the showers and by the toilets. Non-skid mats were also observed. The water temperature was tested in both bathrooms and the water temperature in the first bathroom closest to the living room read 116.7 degrees and the water temperature in the second bathroom read 118.9 degrees Fahrenheit.
  • A first aid kit with a tweezer, scissors and thermometer was observed. Also observed was a first aid manual.
  • The facility has a land line telephone - (818)510-0002. It was operational.
  • The hardwired smoke and carbon monoxide combination detectors were tested and were operational.
  • Auditory devices were observed on all outside exiting doors.
  • Required posters were observed.
  • A covered seating area with chairs and little tables for activities were observed outside.
  • Plastic storage cupboards were observed outside.
  • The outside areas were observed to be clean and well maintained.

The following corrections need to be made prior to licensure:
  • The required furniture - 2 beds, 2 chairs, 2 night stands, 2 portable closets, 2 dressers, 2 lamps need to be purchased for Bedroom #1
  • Twin blankets need to be purchased for all 6 beds and extra to allow for changing.
  • Perishable foods for a minimum of 2 days will be purchased prior to accepting the first resident.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Christine Yee
LICENSING EVALUATOR SIGNATURE:

DATE: 01/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/16/2025
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 N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: GRACEFUL ADULT CARE
FACILITY NUMBER: 195850528
VISIT DATE: 01/16/2025
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  • Maintain a computer or a internet device that is dedicated to the clients and meets Title 22 requirements at the facility for client use. Also ensure that there is a computer usage policy that allows all clients to use the computer during reasonable hours.
  • Relocate the metal cabinet used for storage of the cleaning solutions and laundry detergent from the side of the house.


The Applicant will notify the LPA when the corrections are completed and to schedule another visit to clear the facility.

COMPONENT III was conducted with the Anna Armenyan, Applicant.

Exit interview was conducted and a copy was provided.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Christine Yee
LICENSING EVALUATOR SIGNATURE:

DATE: 01/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/16/2025
LIC809 (FAS) - (06/04)
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