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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610498
Report Date: 01/30/2025
Date Signed: 01/30/2025 02:51:28 PM

Document Has Been Signed on 01/30/2025 02:51 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.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:LOS ANGELES ASSISTED LIVINGFACILITY NUMBER:
197610498
ADMINISTRATOR/
DIRECTOR:		ARZUMANYAN, ANUSHFACILITY TYPE:
740
ADDRESS:15216 CHATSWORTH STREETTELEPHONE:
(424) 666-5666
CITY:MISSION HILLSSTATE: CAZIP CODE:
91345
CAPACITY: 6CENSUS: 6DATE:
01/30/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:02 AM
MET WITH:Anush Arzumanyan - AdministratorTIME VISIT/
INSPECTION COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Gary Tan initially met staff Susie Grigoryan who called the Administrator for a One (1) Year Required visit for this facility. LPA explained the reason for the visit. The Administrator arrived ten (10) minutes later.

A tour of the physical plant was conducted at 9:28 AM and the following was noted:

There is only one entrance being utilized at the facility. Screening area is located immediately upon entrance. Sign in sheet, hand sanitizer, gloves and masks are available. The facility had submitted and approved Infection Control and Mitigation plan.

The facility has a designated visitors' area at the backyard. The facility has sufficient stock of PPE in the storage room. The facility has a total of eight (8) bedrooms and three (3) bathrooms. One of the room is designated as an office and the other one is designated for staff use only. One (1) bathroom is also designated for staff use. The facility is fire cleared for six (6) non-ambulatory residents, two (2) of which may be bedridden on Room #5. Hospice waiver for six (6) residents.

Living and dining room furniture were also checked. The living room is neat and clean. The facility maintains a comfortable temperature at 75°F.Dual smoke/carbon monoxide alarms were tested and observed to be operable. Fire extinguishers were last bought on 01/30/25. One (1) is located in the living room area and the other in the bedroom hallway. The facility is equipped with sprinkler system and closed circuit television system in the common areas.

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 covered patio and backyard furniture to accommodate the residents.
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE: DATE: 01/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/30/2025
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: LOS ANGELES ASSISTED LIVING
FACILITY NUMBER: 197610498
VISIT DATE: 01/30/2025
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The Garage is detached to the house, locked and inaccessible to residents and currently being used as tool shed and old equipment storage. There is another storage at the back end of the lot but observed to be locked and inaccessible to residents. There is no body of water in the facility.

LAUNDRY ROOM: The laundry room is located in the staff bathroom. Laundry detergents and other cleaning agents were locked in a cabinet along the bedroom hallway by the door. The bathroom/laundry room was observed to be locked during visit.

Food Service/Kitchen area was sufficiently stocked with two (2) days perishable and seven (7) days non-perishable food. Frozen foods are properly wrapped and stored appropriately. Food storage and preparation areas are clean and inaccessible to pests. Knives were observed locked in a kitchen drawer. Cleaning supplies and other toxins will be stored in the cabinet in the bedroom hallway which was locked during visit.

The Clients' rooms are adequately furnished with appropriate furniture and lighting system. Hall ways/passage ways are lit. Clients have sufficient amounts of personal hygiene product which is provided by the licensee.



The bathroom was checked for cleanliness and proper operation. LPA observed the appropriate grab bars in the toilet and shower. The hot water temperature was measured at 112.6°F. Towels and washcloths are not shared. There was enough clean linen available in stock at the cabinet.

Medications: LPA observed medication were kept in a kitchen cabinet to be locked and inaccessible to residents. There is a complete first aid kit located in the kitchen.

Client records: Client records are reviewed. Client records appear to be complete and updated.
Staff records: LPA conducted a complete file review of staff records. Staff records appeared to be complete and updated. Disaster drill was last conducted on 11/28/24. Required posting observed in facility (complaint hot line poster).

Exit interview conducted. Copy of this report issued.
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE:

DATE: 01/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2025
LIC809 (FAS) - (06/04)
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