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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609689
Report Date: 04/28/2025
Date Signed: 04/28/2025 06:52:53 PM

Document Has Been Signed on 04/28/2025 06:52 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:HOLLYWOOD HEALTHY LIVING LLCFACILITY NUMBER:
197609689
ADMINISTRATOR/
DIRECTOR:		AGAZARYAN, GAYANEFACILITY TYPE:
740
ADDRESS:8002 HOLLYWOOD WAYTELEPHONE:
(818) 395-1905
CITY:SUN VALLEYSTATE: CAZIP CODE:
91352
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 6DATE:
04/28/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:30 AM
MET WITH:Siranush Mkhitaryan, StaffTIME VISIT/
INSPECTION COMPLETED:
02:30 PM
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On 4/28/2025 @ 10:30am, Licensing Program Analyst (LPA) Leizl de la Cerra conducted the required 1 year annual inspection with staff/caregiver, Siranush Mkhitaryan. Administrator, Gayane Agazaryan was contacted but was unavailable. LPA was informed by the administrator that Siranush Mkhitaryan was given consent to sign the report.
This is a single story residence consists of four (4) bedrooms and two (2) bathrooms. Fire Clearance was approved on 01/17/2019 for five (5) non-ambulatory residents and one (1) bedridden in bedroom #2. All four (4) bedrooms are designated for resident use
A tour of the physical plant was initiated at approximately 11:55pm and the following was observed:
The smoke alarms and carbon monoxide detector are hard wired and inter-connected. Staff tested the dual smoke/carbon monoxide detector @12:30pm and was observed to be operational. The facility has two fully charged fire extinguishers inspected on 4/18/2025. One fire extinguisher is located in common room area, and the other in the kitchen.

KITCHEN: The facility has a kitchen area that is equipped with a refrigerator, microwave oven and sink. There were adequate supplies of perishable and nonperishable food and dining ware to accommodate a maximum capacity of six (6). Knives are kept in a locked box. There is a staff workstation located at the corner of the kitchen.
BEDROOMS: There are four (4) bedrooms designated for resident use. Bedroom #1 and #2 are private rooms, with bedroom #2 having a bedridden fire clearance (per STD 850). Bedrooms #3 and #4 are shared rooms. The resident's bedrooms are furnished with beds, night stand, chairs, dresser, bedding and linen. The bedrooms have sufficient lighting and closet space.
BATHROOMS: The facility has two (2) bathrooms for the resident's use. Both bathrooms were observed to have the proper fixtures, grab bars, and non-skid mats. The hot water temperature measured between 106°- 110°F.
Naira MargaryanTELEPHONE: (818) 596-4368
Leizl De La CerraTELEPHONE: (818) 454-0632
DATE: 04/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/28/2025
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 S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: HOLLYWOOD HEALTHY LIVING LLC
FACILITY NUMBER: 197609689
VISIT DATE: 04/28/2025
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COMMON AREAS: These included the living room and dining room. The living room was equipped with furniture, a television, tables and sofas. There is a fireplace with a screen. No fireplace tools or fixtures present. The dining area has a large dining room table to accommodate six (6). There were no visible immediate hazards.

GARAGE/LAUNDRY ROOM: The washer and dryer is located in the garage, which is kept locked. The garage is also used as extra storage for non-perishable and emergency food supplies and water.

MEDICATIONS: The medications are kept locked in a kitchen cabinet.

Resident Files: LPA conducted reviews of all six (6) resident's files from 10:45am to 11:45am to insure compliance of licensing forms. Resident files are kept locked in cabinet, located the kitchen.

Staff Files: LPA conducted reviews of three (3) staff member's files from 12:45pm to 1:30pm. Staff files are also kept in a locked cabinet located in the kitchen.

SURROUNDING GROUNDS: The driveway, passageways and entrance to the home was clear of obstruction. All entry and exit doors have a functional auditory alert when the doors open. The backyard of the facility has a patio and backyard furniture with umbrella to accommodate the six (6) residents. The facility backyard has sufficient yard space. LPA did not observe any body of water at this facility.

During the visit today, LPA observed no deficiencies. Technical advisories provided.

An exit interview was held. A copy of this report, technical advisory note was provided

SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Leizl De La CerraTELEPHONE: (818) 454-0632
LICENSING EVALUATOR SIGNATURE:

DATE: 04/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2025
LIC809 (FAS) - (06/04)
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