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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195850414
Report Date: 12/08/2025
Date Signed: 12/08/2025 03:01:01 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 12/08/2025 03:01 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:
12/08/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:13 AM
MET WITH:Kachik Rumelyan, AdministratorTIME VISIT/
INSPECTION COMPLETED:
03:10 PM
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Licensing Program Analyst (LPA) Christine Yee conducted an unannounced required Annual Inspection. Upon arrival at the location, LPA Yee made contact with the home via the telephone number provided in the facility profile and was informed by Andranik Khachatrian, Corporate Officer that the facility doses not have any residents. LPA Yee explained that an annual inspection is still needed. Kachik Rumelyan, Administrator, was contacted and he arrived at 10:32am to conduct the visit. The reason for today's visit was provided.

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. Located in the back is a ADU with an address of 6702 Ben Avenue and is not part of the facility operations. The facility is fire cleared for 5 non-ambulatory residents and 1 bedridden resident. Bedroom #1 is fire cleared for bedridden use. The home is approved for 6 hospice waivers.

On today's visit, LPA Yee conducted a tour or the facility inside and outside to observe the physical plant. The CARE Inspection Tool was not used to conduct the annual inspection today since the facility does not have any residents or staff and there are no files to review.

Per tour of the facility, the following were observed:
  • all the required furniture, fixtures and linens were observed in the living room, dining room, kitchen and bedrooms as it was during the Prelicensing visit.
  • The fire place in the living room is capped off and made inaccessible by a fire screen.
  • Bed linens were on the beds and extras observed in the linen closet.


continued on LIC809-C
NAME OF LICENSING PROGRAM MANAGER: Kristin Heffernan
NAME OF LICENSING PROGRAM ANALYST: Christine Yee
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 12/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/08/2025
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 3
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 N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: TRANQUIL GARDENS ELDERLY LIVING
FACILITY NUMBER: 195850414
VISIT DATE: 12/08/2025
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  • all three common bathrooms are equipped with grab bars and slip resistant mats. Water temperature was not tested since the water heater was turned off due to not having any residents. The Licensee was reminded to check the water temperature prior to accepting the first resident.
  • no perishable foods for a minimum of 2 days was observed. Non-perishable foods were observed but is not sufficient for a minimum of 7 days and needs to be supplemented and must be maintained on the premises once residents are placed in the home. Currently there are no residents. The Licensee was reminded that the required foods be purchased prior to accepting the first resident.
  • The hardwired smoke detectors located in the resident bedrooms, dining room, living room and the combination smoke/carbon monoxide detectors located in the hallways were tested and were operational.
  • Auditory devices located on the front door, the door in bedroom #1 and the backdoor were tested and were operational.
  • Medications will be locked in a kitchen cupboard.
  • First aid kit was observed with a tweezer, scissors and thermometer.
  • First aid manual was observed.
  • Cleaning solutions are stored in a locked cabinet in the common bathroom located by bedroom #3.
  • The facility has current general liability insurance that meets Title 22 requirements
  • The laundry room located towards the left side of the home was observed with a washer and dryer.
  • The attached garage is used primarily for storage.
  • The backyard was observed with seating and a table. The tent covering is in the process of being replaced due damage caused by the winds.
  • The trash cans are in the process of being replaced by the city. Per the administrator, multiple requests were made and the city has not delivered new trash cans.
  • Per tour of the inside and outside of the home, the areas were observed to be clean.
  • The Licensee will create staff and resident files once the licensee accepts residents and hires staff


No deficiencies were cited on today's visit.
Exit interview was conducted and copy of this report was provided.
NAME OF LICENSING PROGRAM MANAGER: Kristin Heffernan
NAME OF LICENSING PROGRAM ANALYST: Christine Yee
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/08/2025
LIC809 (FAS) - (06/04)
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