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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195850091
Report Date: 09/25/2025
Date Signed: 09/25/2025 03:11:21 PM

Document Has Been Signed on 09/25/2025 03:11 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 N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:PRESERVE AT WOODLAND HILLS, THEFACILITY NUMBER:
195850091
ADMINISTRATOR/
DIRECTOR:		SUSAN WEISBARTHFACILITY TYPE:
740
ADDRESS:6221 FALLBROOK AVENUETELEPHONE:
(747) 226-5834
CITY:WOODLAND HILLSSTATE: CAZIP CODE:
91367
CAPACITY: 60CENSUS: 46DATE:
09/25/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:22 AM
MET WITH:Susan WeisbarthTIME VISIT/
INSPECTION COMPLETED:
03:25 PM
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Licensing Program Analyst (LPA) Angela Barutyan conducted an unannounced case management - incident visit at 11:22AM. The purpose of this visit is to conduct an investigation regarding three (3) self-reported incidents that occurred on 09/11/2025 and on an unknown date approximately two (2) months ago. Upon arrival, the LPA met with staff and Executive Director (ED) Susan Weisbarth. Entrance interview conducted.

During today’s visit, LPA Barutyan conducted a brief physical plant tour to ensure there are no health and safety hazards, conducted interviews with three (3) staff members and attempted interviews with two (2) residents, and reviewed and obtained copies of pertinent records.

On 09/11/2025, the Department received an incident report and SOC341 stating that on an unknown date approximately two (2) months ago, Staff #1 (S1) pushed Resident #1 (R1) onto their toilet causing it to break. The incident was reported by Staff #2 (S2) on 09/10/2025. R1 was assessed for injuries immediately after the incident was reported and observed no injuries on R1. R1’s responsible party, the Department, the Long-Term Care Ombudsman, and Adult Protective Services were notified. The facility conducted an internal investigation during which S1 and S2 were suspended and are no longer employed at the facility. ED stated it is unknown if the incident actually occurred due to conflicts and retaliation between S1 and S2. LPA discussed mandated reporting requirements and ED stated that a formal mandated reporter training will be conducted with all staff. LPA also attempted an interview with R1.

On 09/16/2025, the Department received an incident report stating that on 09/11/2025 at 08:26AM, Staff #3 (S3) mistakenly administered Resident #2’s (R2) morning medications to R1 due to confusion of the residents’ similar room numbers. Report Continued on LIC 809-C.

NAME OF LICENSING PROGRAM MANAGER: Kristin Heffernan
NAME OF LICENSING PROGRAM ANALYST: Angela Barutyan
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/25/2025
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 N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: PRESERVE AT WOODLAND HILLS, THE
FACILITY NUMBER: 195850091
VISIT DATE: 09/25/2025
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The medications administered to R1 consisted of Allopurinol 100mg, Atorvastatin 40mg, Gabapentin 100mg, Losartan 25mg, Quetiapine Fumarate 25mg and 50mg, and Sertraline HCL 100mg. R1 receives Quetiapine Fumarate 25mg in the evening, no other medications that were administered to R1 were on their medication list or orders. S3 observed the mistake immediately and notified facility management. R1’s primary care physician and responsible party were notified. Primary care physician advised for facility to monitor symptoms and not administer R1’s prescribed morning medications for the day. R1 was monitored for changes and did not have adverse effects besides increased sleepiness. S3 received additional medication administration training via online and in-person. LPA interviewed S3 who was knowledgeable in medication administration and verification techniques. The facility was previously cited within the last 12 months on 03/11/2025 and 04/24/2025 for medication administration errors.

On 09/16/2025, the Department received an incident report stating that on 09/11/2025 at 11:55PM, Resident #3 (R3) left the facility unassisted through the back egress door, door #3, which leads to the exit gate. Staff heard the alarm ring and immediately went to the door where they observed R3 standing outside of the community perimeter gate on the sidewalk. Interviews stated that R3 was not outside of the facility for more than one (1) minute and R3 did not wander off the sidewalk. R3 had no injuries. R3 was diagnosed with a urinary tract infection (UTI) which contributed to R3’s confusion and wandering. Facility management held a meeting with NOC shift staff to discuss wandering prevention techniques as R3 tends to wander at nights. Staff have increased their supervision and sit with R3 in the dining room to keep busy as R3 enjoys their company and does not tend to wander if they are not alone. Facility management also conducted an in-person elopement training on 09/25/2025. On 01/07/2025, the facility was previously cited for two (2) elopement incidents and have since increased the delayed egress time from 15 seconds to 30 seconds and replaced the alarms to louder ones that can be heard from the other side of the facility. LPA tested door #3’s delayed egress at 12:16PM which was functional and operating. Staff responded to the alarm immediately and cleared the alarm at 12:17PM.

Pursuant to Title 22, CA Code of Regulations, the following deficiency was cited (refer to LIC 809-D). Civil penalty was assessed in the amount of $250 for repeat violation. Administrator was informed that failure to correct deficiency may result in additional civil penalties.

Exit interview conducted, report issued, and appeal rights provided.

NAME OF LICENSING PROGRAM MANAGER: Kristin Heffernan
NAME OF LICENSING PROGRAM ANALYST: Angela Barutyan
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/25/2025 03:11 PM - It Cannot Be Edited


Created By: Angela Barutyan On 09/25/2025 at 02:41 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: PRESERVE AT WOODLAND HILLS, THE
FACILITY NUMBER: 195850091

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/25/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/02/2025
Section Cited
CCR
87465(h)(4)

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87465 Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored:
(4) All centrally stored medications shall be labeled and maintained in compliance with state and federal laws...
This requirement is not met as evidenced by:
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S3 received training on medication administration after the error and will receive additional training. Administrator stated that staff will receive vendored training by Guardian Pharmacy and will provide proof of the scheduled in-service to LPA by the due date.
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Based on interview and record review, the licensee did not comply with the section cited above as Resident #1 (R1) was administered Resident #2’s (R2)’s morning medications by Staff #3 (S3). This posed a potential health and safety risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Kristin Heffernan
NAME OF LICENSING PROGRAM MANAGER:
Angela Barutyan
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/25/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/25/2025


LIC809 (FAS) - (06/04)
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