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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195850551
Report Date: 04/09/2025
Date Signed: 04/09/2025 07:29:02 PM

Document Has Been Signed on 04/09/2025 07:29 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:GRACEFUL GARDENS SENIOR LIVINGFACILITY NUMBER:
195850551
ADMINISTRATOR/
DIRECTOR:		YEBEYAN, ELIANORAFACILITY TYPE:
740
ADDRESS:7448 MAMMOTH AVE.TELEPHONE:
(323) 401-0000
CITY:VAN NUYSSTATE: CAZIP CODE:
91405
CAPACITY: 6CENSUS: 0DATE:
04/09/2025
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:58 AM
MET WITH:Karpis Arakelyan, ApplicantTIME VISIT/
INSPECTION COMPLETED:
07:35 PM
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Licensing Program Analyst (LPA) Christine Yee conducted an announced Prelicensing and Component III visit to inspect the facility and to ensure that the facility is in compliance with Title 22 requirements. LPA Yee met with Karpis Arakelyan, Applicant and Elianora Yebeyan, Designated Administrator.

The facility is a single storey family home consisting of a living room, dining room, kitchen, 4 bedrooms and 2 full bathrooms. Attached to the home is an accessory dwelling unit that is not part of the facility operations. It has a separate address of 7446 Mammoth Avenue. The facility is fire cleared for 5 NON-AMBULATORY and 1 BEDRIDDEN residents. Bedroom #1 is designated for bedridden use.

The CARE Inspection tool was used on today's visit.

The following was observed on today's visit:
  • the living room was observed with a sofa, love seat, 2 end tables and a coffee table. The fire place was observed covered with a fire place screen. A large screen television is mounted over the fireplace.
  • the dining room was observed with a table and 6 chairs
  • the kitchen is equipped with a stove, a microwave, toaster, a large refrigerator and a small refrigerator for storage of medications, a small table with 4 chairs and a water filtration system. Sufficient plates, cups and bowls were observed for 6 residents. Pots and pans for preparation of meals were observed.
  • Dish soap and cleaning solutions are stored in a locked cupboard under the kitchen sink.
  • Sharp knives are stored in a locked drawer to the right side of the stove.
  • Insufficient non-perishable foods for minimum of 7 days were observed. Perishable foods for a minimum
NAME OF LICENSING PROGRAM MANAGER: Kristin Heffernan
NAME OF LICENSING PROGRAM ANALYST: Christine Yee
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/09/2025
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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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: GRACEFUL GARDENS SENIOR LIVING
FACILITY NUMBER: 195850551
VISIT DATE: 04/09/2025
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  • or 2 days will be purchased prior to accepting the first resident. 4 buckets of emergency food was observed
  • Located in the kitchen is a stacked washer and dryer for residents' laundry.
  • Bedroom #1 was observed with 2 bed, 2 lamps, 1 folding chair, 2 night stands and a built in closet, 2 little covered trash cans. No dressers were observed.
  • Bedroom #2 was observed with 2 beds, 2 night stands, 2 lamps and a built in closet. No dressers or chairs were observed.
  • Bedroom #3 was observed with 2 beds, 2 large sized -2 drawer cupboard that were used for night stands and as a dresser, a built in closet. A chairs was observed.
  • Bedroom #4, used as a office/staff bedroom was observed with a queen size bed, dresser, 2 lamps, a chair and filing cabinet.
  • The following linens were observed on all 6 beds: a mattress cover, a fitted sheet, a flat sheet and a comforter. A total of 7 blankets were observed in the room closet and in the linen closet. Additional twin sized blankets will be purchased to allow for weekly changes.
  • Extra flat sheets, pillow cases, fitted sheets, bath towels, hand towels and face towels were observed in the linen closet in the hallway.
  • Medications will be centrally stored in one of the locked hallway cupboards.
  • Hygiene products, board games and extra cleaning solutions were also stored in a locked hallway closet.
  • A private bathroom located inside bedroom #2 is equipped with a walk in shower stall, a toilet and a single sink. Grab bars, slip resistant mat and a shower chair were observed in the shower, no grab bars were observed by the toilet. Water temperature was tested and read 118.8 degrees Fahrenheit.
  • The common bathroom is equipped with a walk in shower stall, a toilet and a sink. Grab bars and a slip resistant mat were observed in the shower stall. No grab bars were observed by the toilet. Water temperature was tested and read 119.8 degrees Fahrenheit.
  • the resident hallway did not have night lights.
  • The combination smoke/carbon monoxide detectors located in all the bedrooms and hallway were tested and were operational.
  • The only mounted fire extinguisher is located by the front door and kitchen. It was purchased on 4/8/25.
NAME OF LICENSING PROGRAM MANAGER: Kristin Heffernan
NAME OF LICENSING PROGRAM ANALYST: Christine Yee
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/09/2025
LIC809 (FAS) - (06/04)
Page: 3 of 4
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: GRACEFUL GARDENS SENIOR LIVING
FACILITY NUMBER: 195850551
VISIT DATE: 04/09/2025
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  • The auditory devices mounted on the outside exiting glass doors located in the living room, bedroom #1, bedroom #2 and the front door were observed to be operational.
  • postings were observed but was missing the facility visiting hours
  • The facility has a land line telephone. Telephone # is (818)849-6025
  • the backyard has a covered patio furnished with 3 armchairs and a coffee table and located to the back left hand corner is a covered gazebo furnished with a table and 10 chairs and 2 foot rests.
  • trash cans were on the streets for trash pickup on Thursday.
  • the front yard was observed to be clean


The following corrections need to be completed prior to licensure:
  • purchase additional light warm blankets in quantities to allow for weekly changing or as needed
  • post the facility's visiting hours
  • purchase additional non-perishable foods to meet Title 22 requirement for a minimum of 7 days.
  • update facility sketch to include the meeting point and the location of the shut off valves
  • purchase dressers for bedroom #1 and bedroom #2
  • install grab bars by the toilets in the private and common bathroom
  • place night lights in the hallway
  • purchase a chair for bedroom #1 and bedroom #3 and 2 chairs for bedroom #2.


The following needs to be addressed after licensure if not already addressed with the above corrections:
  • provide an internet usage plan for residents
  • include a fire safety plan for emergency preparedness and for bedridden residents
  • Licensee will purchase General liability insurance in the amount of $1 million per occurrence and a total aggregate of $3 million dollars when licensed. A certificate of insurance naming the Department as the certificate holder to be provided to the Department.
  • Licensee will purchase the required perishable foods for a minimum of 2 days prior to accepting the first resident.
Licensee will contact LPA Yee when the corrections have been completed.

Component III was conducted with Karpis Arakelyan and Elianora Yebeyan on today's visit.
Exit interview was conducted.
NAME OF LICENSING PROGRAM MANAGER: Kristin Heffernan
NAME OF LICENSING PROGRAM ANALYST: Christine Yee
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/09/2025
LIC809 (FAS) - (06/04)
Page: 4 of 4