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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609918
Report Date: 01/21/2026
Date Signed: 01/21/2026 03:16:46 PM

Document Has Been Signed on 01/21/2026 03:16 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 S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:TARZANA SENIOR LIVING INCFACILITY NUMBER:
197609918
ADMINISTRATOR/
DIRECTOR:		AYVAZYAN, SARGISFACILITY TYPE:
740
ADDRESS:5236 OTIS AVETELEPHONE:
(747) 253-0007
CITY:TARZANASTATE: CAZIP CODE:
91356
CAPACITY: 6CENSUS: 6DATE:
01/21/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:00 PM
MET WITH:Sargis AyvazyanTIME VISIT/
INSPECTION COMPLETED:
03:30 PM
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At approximately 12:00 p.m. on 01/21/2026, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced annual inspection. LPA met with the administrator and disclosed the reason for the visit.

The facility was last visited on 11/27/24 for an annual visit. It is a single story building with seven (07) bedrooms, three (03) bathrooms, kitchen, garage, common areas, and outdoor areas. It has an approved fire clearance for six (06) nonambulatory residents, of which six (06) may be bedridden. The facility serves residents with dementia. Approved hospice waivers for four (04). Surveillance cameras are used in common and exterior areas.

The main entrance was gated with a doorbell for entry. LPA observed a maintained front yard and a ramp in good condition leading to the main entrance. Postings at the front included COVID precautions, administrator certificate, facility license, facility sketch, confidential complaints contacts, ombudsman contacts, emergency disaster plan, rights of resident councils, personal rights, theft and loss policy, and “No smoking – Oxygen in use” sign. A screening station was located at the main entrance and contained a digital thermometer, visitor log, masks, and sanitizer. Walls, floors, windows, screens, and blinds were clean and in good repair. One (01) resident was observed in the dining room eating lunch. Three (03) residents were observed watching television and talking with one another. Two (02) residents were asleep for the duration of the visit. Two (02) staff members were observed cleaning and taking resident vital signs. A whiteboard was hung in the living room denoting the date, staff present, and meal times for the day. Board games, puzzles, reading materials, and exercise equipment were provided in the living room. A fireplace was covered and turned off. Medications were locked in a closet by numeric keypad near the main entrance. Two (02) hallway closets contained an adequate supply of extra linens and towels. A locked office in the rear of the facility contained personnel and resident files.

NAME OF LICENSING PROGRAM MANAGER: Naira Margaryan
NAME OF LICENSING PROGRAM ANALYST: Nicholas Reed
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 01/21/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/21/2026
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 S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: TARZANA SENIOR LIVING INC
FACILITY NUMBER: 197609918
VISIT DATE: 01/21/2026
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The facility has seven (07) bedrooms. One (01) bedroom is designated as a staff room. The staff room was locked and free of hazards. All bedrooms contained a chair, lamp, nightstand, storage, and a bed with adequate bedding. All furnishings were clean and in good condition.

The facility has three (03) bathrooms. One (01) bathroom is private to Bedroom #3, and two (02) are shared. All bathrooms contained liquid soap, paper towels, trash can with a tight fitting lid, grab bars near the toilet and shower, and a non-skid mat in the shower. At approximately 12:15 p.m. LPA measured the water temperature in the southern most bathroom to be 110.1 degrees Fahrenheit.

LPA observed adequate supplies of perishable and non-perishable foods in the kitchen. Appliances were in good condition. The stove surface and hood were clean. Sharps and cleaning solutions were locked under the sink. LPA called out from the house telephone at approximately 12:45 p.m. The house telephone was deemed operational. LPA also observed wireless internet was available for resident use. The garage was locked and contained a washing machine and dryer in working order, detergents, chemicals, and extra supplies.

LPA observed two (02) covered patio areas in the rear and side of the facility. The patios contained furniture in good condition along with potted plants and workout equipment.

All emergency exit paths were free from obstructions. The exit gate was unlocked. Auditory alarms were turned on and functioning. Fire sprinklers were located throughout the facility. At approximately 1:10 p.m. LPA observed a fully charged fire extinguisher in the kitchen. A complete first aid kit was posted next to the fire extinguisher. At 1:30 p.m., smoke and carbon monoxide detectors were tested and operational.

At 1:45 p.m. LPA reviewed staff and resident files. All files were complete and available for audit.

During today's inspection, the facility was in compliance with Title 22 regulations. No immediate health or safety concerns were observed during today’s visit.

Exit interview conducted. Copy of report provided.

NAME OF LICENSING PROGRAM MANAGER: Naira Margaryan
NAME OF LICENSING PROGRAM ANALYST: Nicholas Reed
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 01/21/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/21/2026
LIC809 (FAS) - (06/04)
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