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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610785
Report Date: 09/12/2025
Date Signed: 09/12/2025 12:13:08 PM

Document Has Been Signed on 09/12/2025 12:13 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:TUJUNGA RESIDENTIAL CAREFACILITY NUMBER:
197610785
ADMINISTRATOR/
DIRECTOR:		AYVAZYAN, ZHIRAYRFACILITY TYPE:
740
ADDRESS:9820 MARNICE AVETELEPHONE:
(818) 212-5050
CITY:TUJUNGASTATE: CAZIP CODE:
91042
CAPACITY: 6CENSUS: 0DATE:
09/12/2025
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:11 AM
MET WITH:ZHIRAYR AYVAZYAN - AdministratorTIME VISIT/
INSPECTION COMPLETED:
12:15 PM
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Licensing Program Analyst (LPA) Jose Tan conducted an announced Pre-Licensing Inspection with the applicant representative and Administrator ZHIRAYR AYVAZYAN. An application to operate a Residential Care Facility for the Elderly (RCFE) was received by Community Care Licensing (CCL) on 02/20/25. A fire clearance was approved on 03/18/25 for six (6) non-ambulatory residents, one (1) of which maybe bedridden on Room #3. The applicant will also be requesting a hospice waiver to retain six (6) residents. The smoke alarms and carbon monoxide detector are dual and inter-connected. The facility has a brand-new fire extinguisher located in the kitchen and last purchased on 08/23/25.

Facility is a single storey home. Today's site visit consisted of LPA touring the physical plant at 9:23 AM inside and outside and observed the following:

KITCHEN: The facility has a Kitchen area that is equipped with a refrigerator, stove/oven, microwave oven and sink. There was an adequate supply of non-perishable food items observed. Perishable food items 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 cabinet. Cleaning supplies observed locked in the cabinet beside the washer and dryer.

BEDROOMS: There are three (3) bedrooms designated for client use, all shared. The bedrooms were observed to have appropriate furniture and sufficient lighting.

Auditory alarms were tested and observed to be operational. Facility appears to be clean and in good repair. Appliances in the kitchen appeared to be functional. The facility has a working telephone and internet on the premises. (continued on LIC 809-C)

NAME OF LICENSING PROGRAM MANAGER: Troy Agard
NAME OF LICENSING PROGRAM ANALYST: Jose Gary Tan
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/12/2025
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.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: TUJUNGA RESIDENTIAL CARE
FACILITY NUMBER: 197610785
VISIT DATE: 09/12/2025
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(continued from LIC 809)

BATHROOMS: The facility has three (3) bathrooms. One (1) is designated for staff use only. The bathrooms were observed to have the proper fixtures, grab bars, and non-skid mats. The hot water delivered in the bathrooms measured at a range of 113.4°F to 116.8°F

COMMON AREAS: These included the living room and dining room areas. The living room has a couch, chair, table, and television. There is a shaded area with furniture in the backyard for residents' use. The dining room has a table large enough to seat six (6) residents.



LAUNDRY ROOM: The laundry area is located adjacent to the kitchen. Laundry detergent, cleaning agents and other toxins are kept locked in the laundry cabinet. GARAGE is attached to the house but has no access from the inside, it is also being used as emergency food, PPE, tools and other miscellaneous storage.

MEDICATIONS: Medications will be kept locked in a cabinet in the kitchen. Complete First aid kit is located in the kitchen.

SURROUNDING GROUNDS: The driveway, passageways and entrance to the home was clear of obstruction. All entry and exit doors have a functional. The swimming pool is appropriately fenced and observed to be locked during visit. There is a sitting area in the front yard for residents to conduct outdoor activities. The backyard is fenced and has proper locking mechanism.

Component III was waived as approved by LPM Troy Agard as the licensee has another existing facility.

Pursuant to Title 22, Division 6 of the CA Code of Regulations, the facility's physical environment appears to be compliant and ready to be licensed. CAB will be advised and a copy of this report provided

Exit interview conducted. Copy of this report issued.

NAME OF LICENSING PROGRAM MANAGER: Troy Agard
NAME OF LICENSING PROGRAM ANALYST: Jose Gary Tan
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2025
LIC809 (FAS) - (06/04)
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