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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195850414
Report Date: 12/17/2024
Date Signed: 12/17/2024 12:33:19 PM

Document Has Been Signed on 12/17/2024 12:33 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/
DIRECTOR:		RUMELYAN, KACHIKFACILITY TYPE:
740
ADDRESS:6704 BEN AVENUETELEPHONE:
(818) 792-8774
CITY:NORTH HOLLYWOODSTATE: CAZIP CODE:
91606
CAPACITY: 6CENSUS: 0DATE:
12/17/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:KACHIK RUMELYAN - Administrator TIME VISIT/
INSPECTION COMPLETED:
12:40 PM
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Licensing Program Analysts (LPA) Erica Mosley arrived at the facility unannounced to conduct a required annual visit and arrived at the facility at 10:00 a.m. Upon arrival, LPA Mosley rang the doorbell and spoke to the Administrator over the doorbell and informed them of the visit. The Administrator arrived shortly thereafter. The LPA met with KACHIK RUMELYAN– Administrator and explained the reason for the visit. The LPA entered the facility at 10:20 a.m. The facility currently has no residents. The 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.
The home is a single-story family home consisting of a living room, dining room, kitchen, 4 bedrooms, 3 full bathrooms and an 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.

KITCHEN: The LPA inspected the kitchen/food service area at 10:22 a.m. Knives and sharps were observed in a locked drawer. Kitchen appliances were in operable condition. The facility has a sufficient supply of seven (7) day non-perishable food. Food pantries were checked for proper labels and expiration dates. The kitchen faucet was measured for hot water temperature, and it measured 108.5 degrees Fahrenheit at 10:31 a.m. LPA observed an adequate amount of emergency food and water located in the kitchen cabinet storage.

COMMON AREAS: At the time of the visit, furniture in the common areas was observed to be in good condition. The facility maintained a comfortable temperature. At 11:24 a.m., hardwire combination of smoke / carbon monoxide detector and fire doors were tested and operational at the time of the visit. The fire extinguisher was observed and fully charged on 12/15/2024. The LPA observed required postings throughout the common space. Activities were observed in the common areas. The LPA observed the fireplace to be adequately screened.

(PAGE 1) Report Continued on LIC 809C PAGE 2...

SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Erica Mosley
LICENSING EVALUATOR SIGNATURE: DATE: 12/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/17/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
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: 12/17/2024
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(PAGE 2) Report Continued from LIC 809 PAGE 1...

RESTROOMS: There are three (3) total restrooms all designated for resident use. Restrooms were observed to be equipped with nonskid surfaces. Grab bars were observed in all restrooms. The restrooms were sufficiently stocked with supplies and paper towels. The water temperature was measured in all resident restrooms between 106.5-108.4 degrees Fahrenheit all within the required range. Cleaning supplies are kept in a locket cabinet in the bathroom adjacent to RM#3.

BEDROOMS: There are four (4) total bedrooms in the facility; two (2) are designated as private resident rooms and two (2) as shared, double occupancy room. All resident rooms were observed to be furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting.

GARAGE/OUTDOORS: The backyard has a covered patio area with patio furniture including a table and chairs for resident use. All passageways were observed to be clear. LPA observed one (1) self-latching gate. There were no bodies of water noted at the time of the visit. Washer and dryer are located in the laundry room in the back yard of the facility which remains locked at all times. A sufficient supply of laundry detergent was noted in the locked laundry room along with other chemicals and cleaning products. The garage has extra furniture and supplies and remains locked at all times.

MEDICATIONS: Medications are centrally stored in a locked cabinet in the kitchen area.

RECORDS: Resident and staff records are stored in a locked filing cabinet which is currently located in the dining room area.

LPA obtain the following documents: LIC 500 Personnel Roster and current liability insurance.

No deficiencies were cited during today’s inspection. Exit interview conducted. A copy of the report was provided.

SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Erica Mosley
LICENSING EVALUATOR SIGNATURE:

DATE: 12/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2024
LIC809 (FAS) - (06/04)
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