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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191220759
Report Date: 07/15/2025
Date Signed: 07/15/2025 03:41:05 PM

Document Has Been Signed on 07/15/2025 03:41 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:KIM'S LOVE & CAREFACILITY NUMBER:
191220759
ADMINISTRATOR/
DIRECTOR:		MASTERSON, KIMBERLY YVONNEFACILITY TYPE:
740
ADDRESS:24107 VICTORY BLVDTELEPHONE:
(818) 340-2213
CITY:WEST HILLSSTATE: CAZIP CODE:
91307
CAPACITY: 6CENSUS: 3DATE:
07/15/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:15 PM
MET WITH:Kimberly MastersonTIME VISIT/
INSPECTION COMPLETED:
03:45 PM
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At approximately 12:15 p.m. on 07/15/25, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced annual inspection. LPA met with the licensee and disclosed the reason for the visit.

The facility was last visited on 05/28/24 for an annual visit. It is a single story building with four (04) bedrooms, two (02) bathrooms, kitchen, common areas, pool, and outdoor areas. It has an approved fire clearance for six (06) nonambulatory residents. Approved hospice waiver for one (01).

The front gate was unlocked, and the front yard was well maintained. There was a shaded seating area under the front porch with furniture in good condition and exercise equipment. A screening station at the front contained a visitor log, digital thermometer, hand sanitizer, and test kits. Walls, floors, ceilings, windows, and screens were clean and in good repair. At 12:30 p.m. LPA measured the room temperature to be 73 degrees Fahrenheit. Postings at the front and in the kitchen included Ombudsman contacts, confidential complaint contacts, facility license, administrator certificate, rights of resident councils, emergency disaster plan, a blank copy of an admission agreement, and resident rights. The living room contained furniture in good repair, reading material, an office space, and an appropriately covered fireplace.

LPA observed an adequate supply of perishable and non-perishable food in the kitchen and pantry. All surfaces were clean. The stove hood was sanitary and newly remodeled. Sharp objects were locked under a dining room counter. Cleaning solutions were locked under the sink. Medications were locked above a pantry. At approximately 12:45 p.m. LPA observed a fully charged fire extinguisher in the kitchen. It was purchased on 01/16/25 and had a receipt attached. A locked storage closet near the main entrance contained cleaning supplies. A laundry area located near the kitchen contained a washer and dryer in good condition. LPA also observed a fully-stocked first aid kit by the appliances.

NAME OF LICENSING PROGRAM MANAGER: Naira Margaryan
NAME OF LICENSING PROGRAM ANALYST: Nicholas Reed
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.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: KIM'S LOVE & CARE
FACILITY NUMBER: 191220759
VISIT DATE: 07/15/2025
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The facility had four (04) bedrooms. Two (02) bedrooms are designated for staff. Both staff rooms were free of hazards and clean. Bedroom #3 was private and Bedroom #2 was shared. All bedrooms contained a chair, nightstand, lamp, storage, and bed with adequate bedding. All furnishings were clean and in good condition. All emergency exits were unlocked and free of obstructions. Two (02) out of two (02) auditory alarms on resident bedroom exits were on and operational. Two (02) out of two (02) auditory alarms at the front and rear exits were also on and operational.

The facility had two (02) bathrooms. All bathrooms contained liquid soap, paper towels, handwashing instruction signs, trash cans with tight fitting lids, grab bars near the toilet and shower, and a non-skid mat in the shower. At approximately 1:00 p.m. LPA measured the water temperature in the large bathroom to be 107.2 degrees Fahrenheit.

The back yard was well maintained. A storage shed was locked and contained gardening tools. The pool was fenced and the gate was locked with a padlock. A covered seating area was located by the pool. Furniture was in good condition. All emergency exit paths were free from obstructions. Two (02) out of two (02) exit gates were unlocked. At 1:30 p.m. LPA tested the carbon monoxide and smoke detector to be operational.

At approximately 1:40 p.m. LPA reviewed resident and personnel files. All files were complete and available for audit.

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

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: 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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