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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610804
Report Date: 09/23/2025
Date Signed: 09/23/2025 11:23:49 AM

Document Has Been Signed on 09/23/2025 11:23 AM - 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 HOME SENIOR CAREFACILITY NUMBER:
197610804
ADMINISTRATOR/
DIRECTOR:		KEVEYAN, GURGENFACILITY TYPE:
740
ADDRESS:7244 WILBUR AVETELEPHONE:
(808) 498-2094
CITY:RESEDASTATE: CAZIP CODE:
91335
CAPACITY: 6CENSUS: 0DATE:
09/23/2025
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:15 AM
MET WITH:Gurgen Keveyan, LicenseeTIME VISIT/
INSPECTION COMPLETED:
11:55 PM
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At 9:30 AM, Licensing Program Analyst (LPA), Huma Rahimi conducted an announced Pre-Licensing visit to the above facility and met with Gurgen Keveyan, Licensee, and explained the reason for the visit. At the time of this visit LPA did not observe any residents present in the facility. Fire Clearance dated 08/05/2025 and received for six (6) Non-ambulatory residents of which one (1) is Bedridden in bedroom #1. The purpose of today’s visit is to inspect the facility to ensure that the facility is in compliance with rules and regulations under California Code of Regulations, Title 22, Division 6. The facility is a single-story building. Today's site visit consisted of LPA touring the physical plant inside and outside and observed the following:

KITCHEN: The facility has a Kitchen area that is equipped with a refrigerator, oven, and a sink. Stove was observed in a good working condition. At 9:40 AM, LPA observed adequate supplies of perishable and nonperishable food and dining ware to accommodate a maximum capacity of six (6). All knives and sharps are observed to be locked in a kitchen drawer and inaccessible to residents. LPA observed a Fire Extinguisher and was last purchased on 07/16/2025. It was observed handing on the wall in the dinning area.

MEDICATION ROOM: The centrally stored medication will be kept in the in the locked cabinet by bedroom #1 and laundry area in the hall. Facility staff and residents files will be kept locked in the same cabinet.



BEDROOMS: There are three (3) bedrooms designated for residents use. All three (3) bedrooms are share. LPA observed that all bedrooms are furnished with beds, dressers and required bedding and linen. The bedrooms have sufficient closet space and have sufficient lighting. Auditory alarms were tested and observed to be operational. The facility will have an awake staff
Continue on LIC 809C
NAME OF LICENSING PROGRAM MANAGER: Nichelle Gillyard
NAME OF LICENSING PROGRAM ANALYST: Huma Rahimi
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/23/2025
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 HOME SENIOR CARE
FACILITY NUMBER: 197610804
VISIT DATE: 09/23/2025
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BATHROOMS: There are two (2) bathrooms at the facility. LPA observed all bathrooms are clean and in a good repair. Properly supplied with toilet papers, soap and paper towels. LPA observed appropriate grab bar and had non-skid mat The water temperature was noted at 112.1°.

LAUNDRY ROOM: The laundry room is located across the bedroom #1. It has a door with a lock and all cleaning supplies and laundry detergents will be kept locked in the laundry room and inaccessible to residents in care. The washer/dryer appear to be in good working condition.

COMMON AREAS: The facility maintains a comfortable temperature at 78°F. The living room and dining area
appeared clean and were properly furnished and has a television. No obstructions and or tripping hazards throughout the facility. LPA observed a working telephone for the facility.

SURROUNDING GROUNDS: The facility has sufficient backyard space. LPA did observe appropriate outdoor furniture in the backyard of the facility that can accommodate six (6) residents, There is no swimming pool or any bodies of water at the facility. The exit was free of any obstruction or hazard.

Garage/Storage: The facility does not have an extra space or a garage.

SMOKE DETECTORS/CARBON MONOXIDE. Smoke detectors and carbon monoxide were located throughout the facility. At 10:10 AM, they were tested and observed to be operational.

Component III was conducted with the Licensee/Administrator.



Facility is in compliance with Title 22 Regulations at this time. This report will be forwarded to the Centralized Application Bureau (CAB) and be notified by the CAB Analyst when your license has been approved.

Exit interview was conducted and with a copy of this report was provided to the Applicant/Licensee
NAME OF LICENSING PROGRAM MANAGER: Nichelle Gillyard
NAME OF LICENSING PROGRAM ANALYST: Huma Rahimi
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2025
LIC809 (FAS) - (06/04)
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