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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610307
Report Date: 07/15/2025
Date Signed: 07/15/2025 01:08:07 PM

Document Has Been Signed on 07/15/2025 01:08 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.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:VILLA GRANADA ASSISTED LIVINGFACILITY NUMBER:
197610307
ADMINISTRATOR/
DIRECTOR:		MUSHEGHYAN, ANAHITFACILITY TYPE:
740
ADDRESS:17412 TILFORD CTTELEPHONE:
(818) 282-4122
CITY:GRANADA HILLSSTATE: CAZIP CODE:
91344
CAPACITY: 6CENSUS: 6DATE:
07/15/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:05 AM
MET WITH:Ruzanna Manukyan, Designee Administrator TIME VISIT/
INSPECTION COMPLETED:
01:15 PM
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On 07/15/25, at 9:05AM, Licensing Program Analyst (LPA) Gina Saucedo arrived at the facility to conduct an unannounced, annual visit. Upon arrival, LPA met with caregiver Tolkyn Bogumbayeva and disclosed the purpose of the visit. The designee administrator- Ruzanna Manukyan was called and arrived about thirty (30) minutes later.

LPA asked for the census, resident, and staff files.

The facility tour started 10:15AM. Temperature of facility wall thermostat was observed at 74 degrees Fahrenheit. The facility has a signal system.

There is a backyard which has two (2) outdoor furniture tables for outdoor activities. There is no pool or garage. There are two (2) storage houses in the backyard filled with extra mattresses, and other items. The washer and dryer is also located in the backyard. There is an extra refrigerator in the backyard with food.

Living and dining room furniture is accessible for six (6) residents. There is a television and enough seating for six (6) residents. Furniture was observed to be in good condition. There is no fireplace. There is smoke detectors and carbon monoxide detectors all over the house. The smoke detectors and carbon monoxide are hardwired and interconnected and were tested. They were functional.


809C-continued

NAME OF LICENSING PROGRAM MANAGER: Troy Agard
NAME OF LICENSING PROGRAM ANALYST: Gina Saucedo
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/15/2025
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 S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: VILLA GRANADA ASSISTED LIVING
FACILITY NUMBER: 197610307
VISIT DATE: 07/15/2025
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Medications-LPA observed the medication cabinet to be in the kitchen area stored and locked inaccessible to residents.

The first aid kit is stored in a cabinet area at the entrance of the facility along with extra PPE’s items.

Kitchen area was sufficiently stocked with seven (7) days of perishable and seven (7) days of non-perishable food. There is one (1) refrigerator in the kitchen area. The cabinets have canned goods. Sharps are kept secured and locked in one of the cabinets on your left-hand side, under the kitchen sink there is toxins/chemicals that are inaccessible to residents. There is one (1) fire extinguisher located against the wall in the kitchen area fully charged and dated March 2025. There is one (1) phone line located in the kitchen area.



Bedrooms: There are four (4) bedrooms. Two (2) of the bedrooms are shared and the other two (2) bedrooms are single, occupied. One (1) of the bathrooms, is for staff use only that is locked and inaccessible to the residents. This bathroom has extra toxins and hygiene for the residents. There is one (1) bathroom on your left-hand side of the entrance of the facility that can be used by staff and the residents. All four (4) bedrooms are properly furnished with proper lightning. The bathrooms have proper toiletry and grab bars. The bathroom temperature of the water is within regulations. It reads between 117-118 Fahrenheit. Let it be noted, there is an ADU attached to the property with a different address.

Administrative: The Insurance plan is updated, Emergency Disaster Plan, House Rules, Theft and Loss, YES sign, Rights of Resident Councils, Resident's Rights, Residential Infection Control Plan, Ombudsman, Employee Schedule, Resident Roster and Facility Sketch are against the wall at the entrance of the facility on your left hand side. The insurance has an expiration date of 09/2025. Fire Drill and Disaster completed January 2025, Fire Drill also completed April 2025.



There were two (2) staff providing care and supervision.

An exit interview was conducted, no citation(s) were issued, and a copy of this report was given to the administrator.
NAME OF LICENSING PROGRAM MANAGER: Troy Agard
NAME OF LICENSING PROGRAM ANALYST: Gina Saucedo
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2025
LIC809 (FAS) - (06/04)
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