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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195850534
Report Date: 12/12/2024
Date Signed: 12/16/2024 06:54:41 AM

Document Has Been Signed on 12/16/2024 06:54 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 744 P STREET, MS 9-14-8201
SACRAMENTO, CA 95814
FACILITY NAME:COMPLETE HARMONY BOARD AND CARE INCFACILITY NUMBER:
195850534
ADMINISTRATOR/
DIRECTOR:		GALSTYAN, MARGARITFACILITY TYPE:
740
ADDRESS:14912 GILMORE STTELEPHONE:
(818) 425-2317
CITY:VAN NUYSSTATE: CAZIP CODE:
91411
CAPACITY: 6CENSUS: DATE:
12/12/2024
TYPE OF VISIT:OfficeANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:NURITSA MARTINYANTIME VISIT/
INSPECTION COMPLETED:
10:17 AM
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Facility Type: Residential Care Facility for the Elderly
Application Type: Change of Ownership
Capacity: 6
Census (if any clients in care): Unknown
COMP II Participants: NURITSA MARTINYAN
Interview Method: Telephone interview

On December 12, 2024, applicant/administrator participated in COMP II. Identification of the applicant and administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, applicant and administrator confirmed the understanding of the California Code Title 22 Regulations. Signed LIC 809 with copy of photo ID have been obtained.
During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas:
1. Facility operation: License type, client/resident populations, and program
2. Admission Policies
3. Staffing requirements & Training
4. Restricted/Prohibited Health Conditions
5. General provisions
6. Emergency Preparedness
7. Complaints & Reporting
8. Pre-licensing readiness
SUPERVISORS NAME: Jude De La Concepcion
LICENSING EVALUATOR NAME: Bethany Hunter
LICENSING EVALUATOR SIGNATURE: DATE: 12/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/12/2024
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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