195850588-5-26-2026-29-AS-MARO-DUFSK9-20260526135621

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 195850588
Report Date: 05/26/2026
Date Signed: 05/26/2026 01:57:32 PM

Document Has Been Signed on 05/26/2026 01:57 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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	GENTLE GUARDIAN SENIOR CARE		FACILITY NUMBER:	195850588
ADMINISTRATOR/ DIRECTOR:	NERSISYAN, NAREK		FACILITY TYPE:	740
ADDRESS:	15556 SATICOY STREET		TELEPHONE:	(818) 450-7206
CITY:	VAN NUYS	STATE: CA	ZIP CODE:	91406
CAPACITY: 6		CENSUS: 6	DATE:	05/26/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:30 AM
MET WITH:	Narek Nersisyan		TIME VISIT/ INSPECTION COMPLETED:	02:00 PM

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Licensing Program Analyst (LPA) Martha Arroyo arrived at the facility unannounced to conduct the required annual visit today at 09:30am. Upon arrival, the LPA was greeted by staff who then contacted the Administrator, Narek Nersisyan and informed them of the visit. The Administrator arrived at approximately 10:10am and the reason for the visit was explained. Entrance interview conducted.

Beginning at 10:15am, the LPA along with the Administrator 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. The following was observed:

Kitchen: The LPA inspected the kitchen/food service area at approximately 10:17am. Knives and sharps were observed in a kitchen drawer locked and inaccessible at the time of the visit. Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. Cleaning supplies were observed under the kitchen sink inaccessible to residents at the time of the visit. At 10:19am, the hot water temperature was measured in the kitchen sink at it measured at 109.8 degrees Fahrenheit.

Common Areas: This includes the living room and dining room. Furniture in the common areas was observed to be in good condition at the time of the visit. The facility maintained a comfortable temperature. Required postings were observed throughout the common space. There is a working telephone on premises. Fire extinguisher was observed to be new with a purchase date of 05/26/2026. The LPA observed an adequate amount of emergency food and water. At 10:30am, the smoke detector and carbon monoxide detector were tested and functional at the time of the visit.

Report Continued on LIC 809C...

NAME OF LICENSING PROGRAM MANAGER: Desaree Perera
NAME OF LICENSING PROGRAM ANALYST: Martha Arroyo
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/26/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2026

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: GENTLE GUARDIAN SENIOR CARE	FACILITY NUMBER: 195850588
	VISIT DATE: 05/26/2026

NARRATIVE

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Report Continued from LIC 809...

Garage: The garage does not have direct access from the house and is currently being used as storage.

Laundry: Washer and dryer were observed in the backyard. Detergents and toxins were observed locked at the time of the visit.

Restrooms: There are three (3) restrooms for residents use. Bathroom were clean and sanitary and in operating condition with grab bars and non-skid surfaces. The bathrooms were sufficiently stocked with supplies and paper towels. Starting at 10:23am, the hot water temperature was measured in all three (3) bathrooms, and they all measured within the required range of 105 – 120 degrees Fahrenheit at the time of the visit.

Bedrooms: There are four (4) bedrooms for residents use. Two (2) bedrooms are designated as private / single occupancy, and two (2) bedrooms are designated as shared / double occupancy. Bedrooms were observed to be furnished appropriately with appropriate furnishings, and sufficient lighting. Additional clean linens and towels were observed in a closet in the hallway.

Outdoors: The front yard has a covered patio area with patio furniture for residents’ use. There is one (1) side gate for emergency purposes. All passageways were observed to be clear of any obstructions. No bodies of water noted at the time of the visit.

Records: Record review began at approximately 10:35am

Six (6) resident files were reviewed for, but not limited to, the following: signed admission agreements, current medical assessments with TB results, preplacement appraisal, consent for treatment form, and updated/current appraisal & needs and services plan. All files were in order.

Three (3) personnel files including the current Administrator’s file were reviewed for, but not limited to: personnel records, health assessments with negative TB test results, criminal record clearances, first aid/CPR training, and the appropriate yearly training. All personnel files were complete. The Administrator’s Certificate is valid until January 2027.

Report Continued on LIC 809C...

NAME OF LICENSING PROGRAM MANAGER: Desaree Perera
NAME OF LICENSING PROGRAM ANALYST: Martha Arroyo
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/26/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2026

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

FACILITY NAME: GENTLE GUARDIAN SENIOR CARE	FACILITY NUMBER: 195850588
	VISIT DATE: 05/26/2026

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Report Continued from LIC 809C...

Emergency Disaster Planning: The LPA reviewed the facility's infection control plan and emergency disaster plan. The facility’s policies and procedures as they pertain to infection control are adequate. The LPA observed the emergency disaster plan to be complete. Emergency disaster drills conducted quarterly as per regulation.

Medications: Medications review began at approximately 12:15pm. Medications are centrally stored and kept in a locked cabinet by the kitchen. All medications including PRNs were labeled, stored, and locked inaccessible to residents in care. Per records review, 1 out of 6 residents records did not have updated start dates on centrally stored records. The Administrator stated all medication records will be reviewed and updated.

The following deficiencies were observed (See LIC 809-D) and cited from the California Code of Regulations, Title 22 and/or California Health and Safety Code.

Exit interview conducted. A copy of report and appeal rights were provided.

NAME OF LICENSING PROGRAM MANAGER: Desaree Perera
NAME OF LICENSING PROGRAM ANALYST: Martha Arroyo
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/26/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2026

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 05/26/2026 01:57 PM - It Cannot Be Edited

Created By: Martha Arroyo On 05/26/2026 at 01:03 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. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: GENTLE GUARDIAN SENIOR CARE	FACILITY NUMBER: 195850588
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/26/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87506(a)

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 is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above as 1 out of 6 resident centrally stored records were not updated, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/05/2026
	Plan of Correction
1 2 3 4	The Administrator agreed to review and update centrally stored medications records for all residents and submit a statement of understanding for Regulation cited and submit to CCL no later than POC due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Desaree Perera
NAME OF LICENSING PROGRAM MANAGER:

	Martha Arroyo
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/26/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2026

LIC809 (FAS) - (06/04)

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