195850551-5-21-2026-29-AS-BBAI-DUAPV9-20260521113846

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 195850551
Report Date: 05/21/2026
Date Signed: 05/21/2026 11:39:29 AM

Document Has Been Signed on 05/21/2026 11:39 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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	GRACEFUL GARDENS SENIOR LIVING		FACILITY NUMBER:	195850551
ADMINISTRATOR/ DIRECTOR:	YEBEYAN, ELIANORA		FACILITY TYPE:	740
ADDRESS:	7448 MAMMOTH AVE.		TELEPHONE:	(323) 401-0000
CITY:	VAN NUYS	STATE: CA	ZIP CODE:	91405
CAPACITY: 6		CENSUS: 0	DATE:	05/21/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:45 AM
MET WITH:	Elianora Yebeyan		TIME VISIT/ INSPECTION COMPLETED:	12:00 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) Brian Balisi arrived at the facility unannounced to conduct a required annual visit at 9:45am. LPA contacted Licensee Elianora Yebeyan and explained the reason for the visit. Shortly after Licensee arrived at approx. 10:00am, LPA toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. There are no residents currently admitted. The facility is a single story family home consisting of a living room, dining room, kitchen, 4 bedrooms and 2 full bathrooms. Attached to the home is an accessory dwelling unit that is not part of the facility operations. It has a separate address of 7446 Mammoth Avenue. The facility is fire cleared for 5 NON-AMBULATORY and 1 BEDRIDDEN residents. Bedroom #1 is designated for bedridden use. The kitchen appeared to be clean and the appliances and fixtures functional during the time of visit. LPA observed a sufficient amount of perishable and non-perishable food at the facility; properly stored. Sharp objects are stored in a locked drawer to the left of the stove. Cleaning supplies were observed kept inaccessible underneath the sink. The resident bedrooms were properly furnished with a bed, night stand, and sufficient lighting for each resident. The bedrooms had appropriate and adequate bedding and linens such as sheets, pillowcases, mattress pads, and blankets. Hallway cabinets were observed to be able to store medication inaccessible for future residents in care. LPA also observed a sufficient amount of non-perishable foods, and linen stored in these cabinets as well. There is a dedicated area for the posting of required documents directly by the entry way and across the hallway cabinets.

NAME OF LICENSING PROGRAM MANAGER: Desaree Perera
NAME OF LICENSING PROGRAM ANALYST: Brian Balisi
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/21/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2026

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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: GRACEFUL GARDENS SENIOR LIVING	FACILITY NUMBER: 195850551
	VISIT DATE: 05/21/2026

NARRATIVE

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LPA observed bathrooms to be clean, properly supplied and had functional fixtures. LPA observed non-skid mats. The hot water was measured in each bathroom between 105 - 120 degrees Fahrenheit. LPA observed cabinets in the bathrooms to store toiletries inaccessible to residents in care.
LPA observed the common areas. These included family room and dining area. The common areas were checked for cleanliness and furniture was checked for functionality during time of visit. There is a fireplace in the living room. It is double screened and there are no tools. The common areas were observed to be properly furnished and relatively clean at the of the visit. There is a staff room and LPA observed it to be empty at this time. It is inaccessible to residents in care.
LPA observed appropriate signage regarding infection control posted throughout the facility. LPA observed sanitizer readily available in areas with high touch surfaces. Common room furniture was observed to be in good condition. The facility maintained a comfortable temperature. Smoke detector(s) and carbon monoxide detectors were operational at the time of the visit. Fire extinguishers were observed fully charged and last purchased 02/2026.
The exterior passageways were clean and clear of any obstructions. A motorized gate is installed at the front entry. The gate is secured against entry from the exterior when closed, but residents may exit the gated area freely at all times, including during emergencies. The back and sides of the house are separated from the front yard by gates. The gate in the backyard has a self-latching mechanism for persons to exit the backyard. LPA observed appropriate furniture for outdoor use. There is no attached garage.There are no bodies of water on the premises at the present time. There are two storage sheds inaccessible to residents in care. LPA observed then to store incontinent supplies, decorations and other items for facility use.
No Records review or medications review conducted during the visit.

Infection control / Emergency Disaster plan: During today’s visit, the LPA reviewed the facility's infection control practices and the facility's emergency disaster plan. The facility’s policies and procedures as it pertains to infection control are adequate. Emergency disaster drills are to be conducted quarterly. The facility’s emergency disaster plan is up to date and is adequate. Both the infection control plan and the emergency disaster plan are reviewed/updated annually by the facility’s administrator. Smoke detectors and carbon monoxide detectors were tested, all alarms were functional at the time of the visit.

During today’s visit LPA obtained a copy of the facilities Limited Liability insurance. Exit interview conducted and copy of the report was issued.

NAME OF LICENSING PROGRAM MANAGER: Desaree Perera
NAME OF LICENSING PROGRAM ANALYST: Brian Balisi
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/21/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2026

LIC809 (FAS) - (06/04)

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