195850528-3-17-2026-29-AS-CYEE-DS95MG-20260316200442

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 195850528
Report Date: 03/16/2026
Date Signed: 03/17/2026 08:50:29 AM

Document Has Been Signed on 03/17/2026 08:50 AM - 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 CARE		FACILITY NUMBER:	195850528
ADMINISTRATOR/ DIRECTOR:	TOROSYAN, GAYANE		FACILITY TYPE:	735
ADDRESS:	7314 CANTALOUPE AVE		TELEPHONE:	(323) 449-0944
CITY:	VAN NUYS	STATE: CA	ZIP CODE:	91405
CAPACITY: 6		CENSUS: 6	DATE:	03/16/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	11:07 AM
MET WITH:	Anna Armenyan, Licensee		TIME VISIT/ INSPECTION COMPLETED:	08:15 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	Licensing Program Analyst (LPA) Christine Yee conducted an unannounced required Annual Inspection and utilized the CARE Inspection Tool. LPA Yee was let into the home by Ainur Konysbayeva, Staff. Anna Armenyan, Licensee was contacted by telephone and she arrived a little later to conduct the visit. Irina Fried arrived at 11:34am to also participate in the visit. The reason for today's visit was provided. 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. On today's visit all 12 domains of the CARE Inspection Tool were reviewed, 6 client and 6 staff files were reviewed and the physical plant, inside and outside, was toured and the following was observed: 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. Dinner ware, utensils, cups were observed. Pots and pans were observed for cooking. Sufficient perishable foods for a minimum of 2 days and non-perishable foods for a minimum of 7 days were observed. The facility also has a emergency food kit that has 60 servings on site. continued on LIC809-C

NAME OF LICENSING PROGRAM MANAGER: Kristin Heffernan
NAME OF LICENSING PROGRAM ANALYST: Christine Yee
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 03/16/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/16/2026

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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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 N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: GRACEFUL ADULT CARE	FACILITY NUMBER: 195850528
	VISIT DATE: 03/16/2026

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the only fire extinguisher located in the kitchen was serviced on 3/9/26
All 3 bedrooms are furnished with 2 beds, 2 night stands, 2 chairs, a shared dresser and portable closets. Bedroom #1 has a French door and is designated as the bedridden room. The beds were set up to the residents' liking. Extra bed linens were observed.
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. Slip resistant mats were also observed. The back bathroom has a shower chair. The water temperature was tested in both bathrooms and the water temperature in the front bathroom read 110.5 degrees and the water temperature in the back bathroom read 109.6 degrees Fahrenheit.
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 detector in the resident bedrooms and the and carbon monoxide/smoke combination detectors located in the resident hallway and in the living room were tested and were operational.
Auditory devices were observed on the 3 outside exiting doors.
Required posters were observed.
The facility has general liability insurance coverage for $1 million per occurrence and $3 million total annual aggregate.
A covered seating area with chairs and little tables for activities were observed in the front of the home.
Plastic storage cupboards were observed outside.
The outside areas were observed to be clean and well maintained. Trash cans located in the front of the property were observed to be tightly sealed.

No deficiencies cited on today's visit.

NAME OF LICENSING PROGRAM MANAGER: Kristin Heffernan
NAME OF LICENSING PROGRAM ANALYST: Christine Yee
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 03/16/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/16/2026

LIC809 (FAS) - (06/04)

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