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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195850685
Report Date: 12/22/2025
Date Signed: 12/22/2025 02:31:56 PM

Document Has Been Signed on 12/22/2025 02:31 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:SHADY GARDEN SENIOR CAREFACILITY NUMBER:
195850685
ADMINISTRATOR/
DIRECTOR:		HAYRAPETYAN, ANNAFACILITY TYPE:
740
ADDRESS:7356 LEESCOTT AVETELEPHONE:
(818) 916-0707
CITY:VAN NUYSSTATE: CAZIP CODE:
91406
CAPACITY: 6CENSUS: 0DATE:
12/22/2025
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:05 AM
MET WITH:Anna HayrapetyanTIME VISIT/
INSPECTION COMPLETED:
12:45 PM
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Licensing Program Analyst (LPA) Sandra Urena conducted a Pre-licensing visit and met with the applicant Anna Hayrapetyan. This is a facility application for a Residential Facility for the Elderly (RCFE) for a capacity of six (6) residents: One (1) ambulatory; four (4) non-ambulatory, and one (1) bedridden resident. Bedrooms #1 & #2 are approved for non-ambulatory and bedroom #4 is approved for bedridden a resident, and bedroom #3 for Ambulatory only. Waiver/granted for hospice care for six (6). Fire Clearance was approved on 09/24/2025.

At 10:25 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.

COMMON AREAS: The living room area is equipped with a television, and a fireplace which has a cover and is permanently attached. There is a dedicated area for the posting of required documents. Smoke and carbon monoxide alarms were tested and functional at the time of the visit. Medications will be stored in a locked rolling cabinet located in the common area. The residents’ and staff files will be stored in a cabinet located in the dining area.
LAUNDRY: There is a laundry area equipped with washer and dryer. The washer and dryer are located in a locked room which also has a restroom with a shower adjacent to the kitchen. Detergents and cleaning supplies will be stored in a locked chest outside the kitchen area.

Continues on LIC 809C...
NAME OF LICENSING PROGRAM MANAGER: Kasandra Lopez
NAME OF LICENSING PROGRAM ANALYST: Sandra Urena
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 12/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/22/2025
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: SHADY GARDEN SENIOR CARE
FACILITY NUMBER: 195850685
VISIT DATE: 12/22/2025
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KITCHEN: Kitchen knives are stored locked and inaccessible in a locked kitchen drawer. A seven-day supply of non-perishable food was availHot water temperature was recorded at 113.5 degrees Fahrenheit. Trash can is in a cabinet compartment next to the sink area. 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. A fire extinguisher is located in the kitchen area, and was purchased on 12/22/2025.

BEDROOMS: There are four bedrooms in total. Bedrooms #1 & #2 are approved for non-ambulatory and bedroom #4 is approved for a bedridden resident. Bedroom # 3 is approved for ambulatory only. All bedrooms were supplied with all required bedding and linens. There is sufficient lighting. Bedroom #1 requires additional drawer space and a closet divider to keep residents’ clothes separated from each other. Bedroom # 2 needs additional drawer.


BATHROOMS: There is a total of three (3) bathrooms. Two (2) full bathrooms with showers, and one (1) bathroom with a shower and bathtub. Bathrooms are equipped with toilets and shower grab bars, and non-skid mats. There are sufficient supplies of towels, paper goods and personal hygiene supplies. Hot water delivered at 113.5 degrees Fahrenheit.

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.


Pre-Licensing is incomplete with deficiencies to be resolved by 12/26/2025. Follow up Pre-licensure LIC809 will be generated upon resolution.

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. The applicant will email the CAB analyst a revised floor sketch to reflect the correct numbers of each bedroom according to the approved inspection by the fire Department Inspector. Additionally, the Applicant will submit with sketch reflecting the staff bedroom and laundry room with bathroom. Exit interview was conducted and reviewed with the applicant. A copy of the report was issued.

NAME OF LICENSING PROGRAM MANAGER: Kasandra Lopez
NAME OF LICENSING PROGRAM ANALYST: Sandra Urena
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2025
LIC809 (FAS) - (06/04)
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