195850604-5-28-2025-29-AS-QHUH-DH4R4J-20250528124138

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 195850604
Report Date: 05/28/2025
Date Signed: 05/28/2025 12:42:08 PM

Document Has Been Signed on 05/28/2025 12:42 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:	GREENBUSH SENIOR LIVING INC		FACILITY NUMBER:	195850604
ADMINISTRATOR/ DIRECTOR:	MOVSESIAN, KAJO		FACILITY TYPE:	740
ADDRESS:	6426 GREENBUSH AVE		TELEPHONE:	(818) 804-9406
CITY:	VAN NUYS	STATE: CA	ZIP CODE:	91401
CAPACITY: 6		CENSUS: 0	DATE:	05/28/2025
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	11:00 AM
MET WITH:	Kajo Movsesian - Applicant		TIME VISIT/ INSPECTION COMPLETED:	01:00 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 Analysts (LPAs) Quoc Huynh and Kelly Dulek conducted a pre-licensing visit to the above noted facility. At 11:00AM, the LPAs met with applicant, Kajo Movsesian. An application to operate a Residential Facility for the Elderly was submitted on 10/18/2024. A dementia program was included in the plan of operation. A Hospice Waiver for 6 (six) has been requested. The facility's fire clearance was approved on 01/22/2025 for two (2) bedridden and four (4) non-ambulatory, with a total capacity of six (6) residents. Component II orientation was completed on 05/01/2025. Component III was completed with the applicant during today's visit. The facility is a single-story home located in Van Nuys. Beginning at 11:05AM, a physical plant tour was conducted. The following was observed: BEDROOMS/BATHROOMS: The facility has four (4) bedrooms. Bedrooms #1, #3, and #4 have a direct access to the outside and is cleared for bedridden residents. Resident rooms are set up with beds, nightstands, lamps, chairs, sufficient clothing storage and closet space. The beds are furnished with box springs, comfortable mattress and clean linen, which includes, a mattress pad, top and bottom linens, pillowcases, and blanket (if needed). Lighting in the rooms appeared adequate. The bedrooms were large enough to allow for easy passage between the beds and furniture with a wheelchair or walker. In addition, no bedroom was used as a passageway to another room, bath or toilet. All rooms were free of odors. All window screens were clean and maintained in good repair. Report Continued on LIC 809-C

NAME OF LICENSING PROGRAM MANAGER: Kristin Heffernan
NAME OF LICENSING PROGRAM ANALYST: Quoc Huynh
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/28/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2025

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: GREENBUSH SENIOR LIVING INC	FACILITY NUMBER: 195850604
	VISIT DATE: 05/28/2025

NARRATIVE

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There are two (2) bathrooms, both shared. The bathrooms have a shower with non-slip mats. The toilet and shower have grab bars. The hot water temperature was tested and measured within the required range of 105*F to 120*F.

COMMON AREAS: Common areas were appropriately furnished, and the lighting was adequate. There is a television, reading materials, and/or activity supplies in the living room. There is a fireplace that was properly screened. There was sufficient space to accommodate both indoor and outdoor activities. All ramps were secure and non-slippery and were positioned at the level where wheelchairs and walkers may enter and exit the facility safely. Alarms on all exterior doors were engaged at the time of visit and functional. In addition, the physical plant is consistent with the submitted facility sketch/floor plan. The facility had emergency lighting, which included but not limited to flashlights. Night-lights were observed throughout the common areas. The facility had emergency food and water available. The facility has central heating and air conditioning to maintain rooms to a comfortable temperature. At 12:33PM, the hardwired combination smoke and carbon monoxide detectors were tested and functioned properly. The fire extinguishers throughout the facility were fully charged and purchased on 05/24/2025. The supply of extra bed and bath linens as well as personal hygiene items were adequate. Extra incontinence supplies and other supplies are located outside in the locked storage shed. There is a washer and dryer closet located in the hallway and observed to be in good condition. There is a functioning telephone on the premises. All required postings are posted near the entrance of the facility.

KITCHEN: Knives are stored in a locked kitchen drawer. The supply of dishes, utensils, pots, pans and drinkware is adequate. The freezer was maintained at zero degrees Fahrenheit and the refrigerator was maintained at 40*F. The supply of nonperishable foods and emergency food supply is adequate. Cleaning supplies are stored in a locked cabinet under the kitchen sink. There are no pesticides or toxins stored in any food storage area or preparation area. Appliances in the kitchen were clean and all appeared functional. Medication will be stored in a locked kitchen cabinet.

Report Continued on LIC 809-C

NAME OF LICENSING PROGRAM MANAGER: Kristin Heffernan
NAME OF LICENSING PROGRAM ANALYST: Quoc Huynh
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/28/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2025

LIC809 (FAS) - (06/04)

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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: GREENBUSH SENIOR LIVING INC	FACILITY NUMBER: 195850604
	VISIT DATE: 05/28/2025

NARRATIVE

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Files will be stored in a separate locked kitchen cabinet. First aid kit was observed to be complete, including a thermometer and a current version of a first aid manual.

OUTDOOR AREA: The exterior passageways were clean and clear of any obstructions. There are two areas at the back of the house with tables and chairs where residents can sit. The outdoor space is property gated. There are two storage sheds in the back yard intended for extra supplies. There are no bodies of water on the premises at the present time.

No corrections required. Exit interview conducted. A copy of the report was issued.

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.

NAME OF LICENSING PROGRAM MANAGER: Kristin Heffernan
NAME OF LICENSING PROGRAM ANALYST: Quoc Huynh
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/28/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2025

LIC809 (FAS) - (06/04)

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