<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195850590
Report Date: 01/16/2025
Date Signed: 01/16/2025 02:21:08 PM

Document Has Been Signed on 01/16/2025 02:21 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:NIRVANA GARDENS ASSISTED LIVINGFACILITY NUMBER:
195850590
ADMINISTRATOR/
DIRECTOR:		GABUZYAN, CHRISTINAFACILITY TYPE:
740
ADDRESS:15801 HART ST.TELEPHONE:
(323) 925-6629
CITY:VAN NUYSSTATE: CAZIP CODE:
91406
CAPACITY: 6CENSUS: 0DATE:
01/16/2025
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:43 AM
MET WITH:Christina GabuzyanTIME VISIT/
INSPECTION COMPLETED:
01:30 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Sandra Urena conducted a Pre-licensing visit and met with the applicant Christina Gabuzyan. This is a new facility application for a Residential Facility for the Elderly (RCFE) for six (6) non-ambulatory residents, one (1) bedridden resident can be admitted and reside in bedroom #3. Fire Clearance was approved on 11/01/2024 for all rooms for non-ambulatory use, and room # 3 for one bedridden resident.

At 10:05 a.m., the LPA, and the Applicant toured the physical plant areas inside and outside to ensure there are no health and safety hazards and that the facility will be following Title 22 Regulations.

KITCHEN: Kitchen knives are stored locked and inaccessible in a locked kitchen drawer. A seven-day supply of non-perishable food was available. The supply of dishes is adequate. Appliances in the kitchen were clean and all appeared functional. Kitchen cleaning supplies will be stored and locked under the kitchen sink. Hot water temperature was recorded at 116.8 degrees Fahrenheit. Trash cans have a tight-fitting lid. There were no pesticides or toxins stored near food, or preparation area. The first aid supplies were complete, including a thermometer and a current version of a first aid manual. Two fire extinguishers were observed; one is located by the office and another one is located in the kitchen area. Both were serviced on 08/13/2024. The applicant will install a ramp with handrails for residents to access the patio area.

BEDROOMS: There are three (3) bedrooms for residents in care. Rooms 1, 2 and 3 will be shared rooms; all bedrooms are cleared for non-ambulatory, and bedroom #3 is cleared for one bedridden resident. All bedrooms were supplied with all required bedding and linens. There is sufficient lighting as well as closet and some space available. Applicant will add additional chest of drawers to bedrooms 1 and 2. Applicant will add two (2) lamps to bedroom #3. Applicant will add handrails to ramp connected to bedroom #3.


LIC 809C...

SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Sandra Urena
LICENSING EVALUATOR SIGNATURE: DATE: 01/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/16/2025
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
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: NIRVANA GARDENS ASSISTED LIVING
FACILITY NUMBER: 195850590
VISIT DATE: 01/16/2025
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
BATHROOMS: There is one full bathroom, with shower and a bathtub. Bathroom is equipped with toilet and shower grab bars, and non-skid mats. There are sufficient supplies of towels, paper goods and personal hygiene supplies. Hot water delivered was at 116.7 degrees Fahrenheit. A small threshold ramp will be installed.

COMMON AREAS: The living room area is equipped with a television, and the fireplace is non-functional and is permanently covered. There is a dedicated area for the posting of required documents at the entrance of the facility. Smoke and carbon monoxide alarms were tested and functional at the time of the visit. Medications will be stored in a locked cabinet in the office area. The residents’ and staff files will be stored and locked cabinets located in the office area. LAUNDRY: There is a laundry area equipped with washer and dryer. The washer and dryer are located in the hallway between the restroom and bedroom # 1. Detergents and cleaning supplies will be stored in a locked cabinet next to the washer and dryer.



SURROUNDING GROUNDS/OUTDOOR AREA: The exterior passageways were clean. The patio is furnished with outdoor furniture for residents’ use, and shade is available. The building has a central entrance for residents and visitors. Left passageway is cleared and has a self-latching gate. The self-latching mechanism is located on the outside of the gate facing the street. An auditory device will be installed to monitor the gate exit. The applicant will have the following items removed or relocated to another area: Bricks, and fencing. A gate will be installed on the right-hand side of the building to prevent residents from wondering to this area.

At the time of the visit the LPA observed one (1) ADU unit. The unit is identified by the address #15801 ½. and is located on the left-hand side of the facility. The ADU unit is separated from the main address by a fence, and is not accessible to residents in care.

Continues on LIC 809C...

SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Sandra Urena
LICENSING EVALUATOR SIGNATURE:

DATE: 01/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/16/2025
LIC809 (FAS) - (06/04)
Page: 2 of 3
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: NIRVANA GARDENS ASSISTED LIVING
FACILITY NUMBER: 195850590
VISIT DATE: 01/16/2025
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Pre-Licensing is incomplete with deficiencies to be resolved by 01/24/2025. Follow up Pre-licensure LIC809 will be generated upon resolution.

· The applicant will install a ramp with handrails for residents to access the patio area.

· Applicant will add additional chest of drawers to bedrooms 1 and 2. Applicant will add two (2) lamps to bedroom #3.

· Applicant will add handrails to ramp connected to bedroom #3.


· An auditory device will be installed to monitor the gate exit.

· The applicant will have the following items removed or relocated to another area: Bricks, and fencing.


· A gate will be installed on the right-hand side of the building to prevent residents from wondering to this area.
  • A small threshold ramp will be installed in the bathroom.


At 1:00 p.m. the applicant completed Component III orientation.

This report will be sent to the Centralized Application Bureau (CAB). You will be notified by the CAB Analyst when your license has been approved. You are not allowed to begin operating until you have been notified that your license has been approved by the CAB Analyst. Failure to comply could affect approval of your license.

Exit interview was conducted and reviewed with the applicant. A copy of the report was issued.

SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Sandra Urena
LICENSING EVALUATOR SIGNATURE:

DATE: 01/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/16/2025
LIC809 (FAS) - (06/04)
Page: 3 of 3