197610712-4-17-2025-31-AS-NSHN-DFTVKF-20250417163016

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610712
Report Date: 04/17/2025
Date Signed: 04/17/2025 04:30:49 PM

Document Has Been Signed on 04/17/2025 04:30 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:	HARMONY GARDEN OF NORTH HILLS INC		FACILITY NUMBER:	197610712
ADMINISTRATOR/ DIRECTOR:	KARAPETIAN, MARINE		FACILITY TYPE:	740
ADDRESS:	16640 CALAHAN STREET		TELEPHONE:	(818) 422-6590
CITY:	NORTH HILLS	STATE: CA	ZIP CODE:	91343
CAPACITY: 6		CENSUS: 0	DATE:	04/17/2025
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	01:00 PM
MET WITH:	Marine Karapetian - Licensee		TIME VISIT/ INSPECTION COMPLETED:	04:30 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 Analysts (LPA) Nadia Shahbazian conducted an announced Pre-Licensing Inspection with Marine Karapetian - Administrator/Licensee at 1:00 pm. An application to operate a Residential Care Facility for the Elderly (RCFE) was received by Community Care Licensing (CCL) on 10/01/2024. Facility's fire clearance is approved for five (5) Non-ambulatory residents and one (1) bedridden resident, for a total capacity of six. Bedroom #1 is appropriated for bedridden resident. The smoke alarms and carbon monoxide detectors are dual and inter-connected. In addition, facility is equipped with two (2) fire doors, near the front entry and bedrooms. The facility has a fire extinguisher purchased on 03/05/2025. Fire extinguisher is located near the dining room exit door. With the assistance of the administrator, a tour of the physical plant was initiated at 1:30pm and the following was observed: KITCHEN: The facility has a Kitchen area that is equipped with a refrigerator, stove, oven, microwave oven and dishwasher. There was an adequate supply of non-perishable food items observed. Perishable food items are not required at this time as there are no residents. Administrator was advised facility needs to carry perishable food items once they admit residents for care. Knives were observed locked in a kitchen drawer. LAUNDRY AREA: The laundry area is located on the side of the kitchen, with a exit door leading to the backyard. Cleaning supplies, detergents and chemicals were observed to be kept in cabinets in laundry area. BEDROOMS: There are four (4) bedrooms, three bedrooms will be used for residents and one bedroom for staff. Bedroom #4 is currently utilized as the staff bedroom/office. Bedroom #1 is designated for the bedridden resident and has an exit door. Each bedroom was furnished with beds, chairs, dresser drawer and closets, bedding and linen. The bedrooms have sufficient lighting and closet space. There is a two-sided non-functional fireplace in bedroom #4. The fireplace is properly screened on both sides, the other side of the fireplace is located in the living room. Continued on 809-C

NAME OF LICENSING PROGRAM MANAGER: Eva Miller
NAME OF LICENSING PROGRAM ANALYST: Nadia Shahbazian
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/17/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2025

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: HARMONY GARDEN OF NORTH HILLS INC	FACILITY NUMBER: 197610712
	VISIT DATE: 04/17/2025

NARRATIVE

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BATHROOMS: The facility has two (2) bathrooms. Bedroom #1 has it's own bathroom with shower. The
other bathroom is located by bedrooms two (2) and three (3). The bathrooms were observed to have the proper fixtures, grab bars, non-skid maths and shower chairs. Hot water delivered in the bathrooms measured at 107.4 degrees Fahrenheit.

COMMON AREAS: These included living room and dining rooms. The dining room has a table large enough to seat six (6) residents. The living room two side tables and a television set. There is a two-sided non-functional fireplace in the living room, properly screened. The other side of the fireplace, is located in bedroom #4. There is a gaming area in the living room and a library by the front hallway. Facility is equipped with cameras in common areas.

MEDICATIONS: Medications will be kept locked in kitchen cabinets. There is a locked small refrigerator dedicated for medication usage, in the kitchen. There is a complete first aid kit and first aid manual, locked in the kitchen cabinet.

SURROUNDING GROUNDS: The driveway, passageways and entrance to the home was clear of obstruction. The backyard of the facility is large enough to hold outdoor activities. Backyard furniture was observed placed underneath a covered patio. There is no swimming pool or body of water. There is a detached garage, currently used as storage. There is an exit door in the dining room, an exit door in bedroom #1, both leading to the backyard. The main entry door will be used as the emergency exit door. All gates leading to the backyard were free of obstruction and had clear pathways.

OFFICE/STAFF WORKSTATION: Bedroom #4 is currently utilized as the staff room/office. The staff room is furnished with a sofa, chairs, desk and a workstation consisting of filing cabinets to store resident and staff records. Facility is equipped with internet access, cable and land line telephone. LPA observed all the required postings displayed in the office area.

In addition to the Pre-Licensing inspection, a Component III power point presentation was also held.
Pursuant to Title 22, Division 6 of the CA Code of Regulations, the facility's physical environment appears to
be compliant and ready for licensure. CAB will be advised and a copy of this report provided.

NAME OF LICENSING PROGRAM MANAGER: Eva Miller
NAME OF LICENSING PROGRAM ANALYST: Nadia Shahbazian
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/17/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2025

LIC809 (FAS) - (06/04)

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