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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195850414
Report Date: 12/18/2023
Date Signed: 12/18/2023 04:33:33 PM

Document Has Been Signed on 12/18/2023 04:33 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 N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:TRANQUIL GARDENS ELDERLY LIVINGFACILITY NUMBER:
195850414
ADMINISTRATOR:RUMELYAN, KACHIKFACILITY TYPE:
740
ADDRESS:6704 BEN AVENUETELEPHONE:
(818) 792-8774
CITY:NORTH HOLLYWOODSTATE: CAZIP CODE:
91606
CAPACITY: 6CENSUS: 0DATE:
12/18/2023
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
08:47 AM
MET WITH:Kachik Rumelyan, ApplicantTIME COMPLETED:
04:40 PM
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Licensing Program Analyst( (LPA) Chrisitne Yee conducted an announced Prelicensing and Component III visit and met with Kachik Remelyan, Applicant and Designated Administrator.

The home is a single storey family home consisting of a living room, dining room, kitchen, 4 bedrooms, 3 full bathrooms and a attached garage. The facility is fire cleared for 5 non-ambulatory residents and 1 bedridden resident. Bedroom #1 is fire cleared for a bedridden resident.

The following were observed on today's visit:
  • The living room is furnished with a sofa, love seat, a armchair, a coffee table and a television. Located in the living room is a fire place that is sealed off with a fire screen since the fire place will not be used.
  • The dining room is furnished with a large table and 8 chairs. A filing cabinet to store resident and staff files were observed.
  • The kitchen is equipped with a stove, dishwasher and a refrigerator. Medications will be stored in a locked kitchen cabinet and sharp knives stored in a locked drawer. 8 sets of dinner plates, salad plates, bowls, glasses and 12 coffee cups were observed. Also observed were 8 of each - forks, knives, tablespoons and teaspoons. Pots, pants and cooking utensils were observed. Dish soap will be stored in a locked cabinet under the kitchen sink. No perishable foods were purchased for today's visit but will be purchased prior to accepting the first resident. Non-perishable foods for 7 days need to be supplemented to meet Title 22 requirements. Located in the kitchen is the only fire extinguisher, purchased on 9/30/23.
  • Bedrooms #1 and Bedroom #3 both contain I bed, 1 chair, 1 night stand, 1 lamp, a dresser and a built in closet in bedroom #1 and a portable closet in bedroom #3. The required bed linens were observed except no blankets were observed. The beds need box springs. Blinds were observed on bedroom
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Christine Yee
LICENSING EVALUATOR SIGNATURE: DATE: 12/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/18/2023
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 N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: TRANQUIL GARDENS ELDERLY LIVING
FACILITY NUMBER: 195850414
VISIT DATE: 12/18/2023
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  • windows. Blinds or curtains needs to be hung on the door in bedroom #1 to allow for privacy. The beds are too low and need box springs. The door in Bedroom #1 leads out to a ramp.
  • Bedrooms #2 and Bedroom #4 are furnished with 2 twin beds, 2 night stands, 2 chairs, 2 lamps, 2 dressers and a shared closet. The required bed linens were observed except there were no blankets. Box springs are needed for the beds. Blinds were observed on the windows.
  • The common bathroom located closes to bedroom #1 is designated for staff use and is equipped with a tub and shower head, a toilet and a sink. A non-skid mat was observed but no grab bars were installed. Water temperature was tested and read 111.6 degrees Fahrenheit.
  • The common bathroom by bedroom #3 has a shower, a toilet and a sink. Toxins and cleaning supplies are stored in a locked cabinet. 18 bath towels, 24 wash clothes and 24 face towels were also observed in the bathroom cabinet. Hygiene products such as tooth paste, tooth brushes, shampoos are stored in cubbies assigned to each resident. Toilet paper and paper towels were also observed. Water temperature was tested and read 106.5 degrees Fahrenheit.
  • The common bathroom by bedroom #4 is equipped with a shower, a toilet, a sink, grab bars and a non-skid mat. Water temperature was tested and read 108.2 degrees Fahrenheit.
  • The hardwired smoke detectors were tested and were operational.
  • The carbon monoxide detectors located in the hallways were tested and were operational.
  • The first aid kit was reviewed and contained the required bandages, tweezer, scissor and a thermometer.
  • A first aid manual was observed.
  • The backyard and front yard was observed to be clean. 4 rattan chairs and 2 rattan love seats were observed covered with a fabric gazebo in the backyard. No bodies of water was observed.

The following deficiencies need to be corrected prior to being licensed:
  • Blankets need to be provided to all the residents and extra quantities to be purchased in quantities to allow for weekly changing or as frequently as needed
  • Blinds/Curtains need to be placed on the door in bedroom #1
  • Box springs need to be obtained for all residents bed
  • Grab bars need to be installed in the staff bathroom located by bedroom #1
  • Non-perishable foods need to be supplemented.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Christine Yee
LICENSING EVALUATOR SIGNATURE:

DATE: 12/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/18/2023
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 N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: TRANQUIL GARDENS ELDERLY LIVING
FACILITY NUMBER: 195850414
VISIT DATE: 12/18/2023
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Applicant will contact LPA Yee once the corrections have been completed.

The following needs to be completed prior to accepting the first resident:
  • perishable foods for a minimum of 2 days must be purchased
  • liability insurance must be purchased to meet Title 22 requirements of $1 million per occurrence and for a total annual aggregate of $3 million.


Component III was conducted with Kachik Rumelyan.

Exit interview was conducted.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Christine Yee
LICENSING EVALUATOR SIGNATURE:

DATE: 12/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/18/2023
LIC809 (FAS) - (06/04)
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