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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195850252
Report Date: 05/06/2025
Date Signed: 05/06/2025 04:42:26 PM

Document Has Been Signed on 05/06/2025 04:42 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:FALLBROOK ELDERLY CARE LLCFACILITY NUMBER:
195850252
ADMINISTRATOR/
DIRECTOR:		HOWE, MARY ANNFACILITY TYPE:
740
ADDRESS:5515 FALLBROOK AVENUETELEPHONE:
(818) 712-0904
CITY:WOODLAND HILLSSTATE: CAZIP CODE:
91367
CAPACITY: 6CENSUS: 5DATE:
05/06/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:07 AM
MET WITH:Mary Ann HoweTIME VISIT/
INSPECTION COMPLETED:
05:00 PM
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Licensing Program Analyst (LPA) Angela Barutyan arrived at the facility unannounced to conduct a required annual visit at 10:07AM. LPA met with staff upon arrival and Administrator Mary Ann Howe who arrived at 10:51AM. Entrance interview conducted.

At 10:11AM, the LPA along with staff, toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations.

KITCHEN: The LPA inspected the kitchen/food service area at 10:11AM. Kitchen appliances appeared clean and were in operable condition at the time of the visit. The facility has a sufficient supply of perishable and nonperishable food. Food labels were inspected and checked for expiration dates and food labels had expiration date clearly marked. Knives and chemicals were locked and inaccessible in the cabinet under the sink. At 10:22AM, LPA observed the auditory exit alarm in the kitchen not functioning during the time of the visit. Administrator stated that a new exit alarm will be installed.

BEDROOMS: There are five (5) bedrooms total; two (2) are private resident bedrooms, two (2) are shared-resident bedroom, and one (1) is a staff room which is kept locked and inaccessible. Bedrooms #1, #3 and #5 have direct exits to the exterior. LPA observed resident bedrooms to be furnished appropriately with clean linens, appropriate furnishings, sufficient lighting, and equipped with functioning auditory exit alarms. At 12:15PM, LPA observed the bathroom door in bedroom #3 to have a hole on the bottom right corner by the hinge, leaving the framing exposed. Administrator stated that the door will be patched and a request for service had been made.

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: 05/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/06/2025
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.

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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: FALLBROOK ELDERLY CARE LLC
FACILITY NUMBER: 195850252
VISIT DATE: 05/06/2025
NARRATIVE
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RESTROOMS: There are three (3) bathrooms for resident use; the full bathroom in the hallway is designated for staff and guests. Resident bedroom #1 and #5 have an attached Jack and Jill bathroom. Resident bedroom #3 has an attached bathroom for private use. Between 10:21AM-10:32AM, hot water temperature was measured in all three (3) bathrooms. Hallway bathroom measured at 117.5 degrees F, which is within the required range of 105-120 degrees F. However, hot water in bedroom #3’s bathroom and the Jack and Jill bathroom measured at 135.0 degrees F and 128.7 degrees F, respectively. Staff lowered the water heater during the visit. LPA re-measured at 12:19PM and hot water was 129.2 degrees F and 127.8 degrees F. LPA measured a final time between 02:22PM-02:26PM and hot water was 109.4 degrees F and 106.1 degrees F.

COMMON SPACES: In the common areas, walls and flooring were checked for cleanliness and


good condition. At the time of the visit, common seating area and dining room furniture was
observed to be in good condition. The LPA observed the required postings in the common hallway. Fire extinguishers were fully charged and last serviced 05/03/2025. Administrator stated that service is scheduled for next week to re-new the fire extinguishers. The facility smoke alarm system is hard wired; the combination smoke and carbon monoxide detectors were tested at 10:48AM and were operable at the time of the visit. At 10:48AM, LPA observed the hallway smoke detector disconnected and placed on the hallway table. Staff stated that the smoke detector was disconnected on Sunday 05/04/2025 because the detector was beeping. Administrator stated that the detector was defective even after battery replacement and a new one will be purchased and installed by tomorrow 05/07/2025.

LAUNDRY: At 10:25AM, LPA observed the laundry unit in the hallway by the staff room and bedroom #3. The door was unlocked and LPA observed detergents and cleaning solutions accessible to residents in care. Staff on shift did not have the code to lock the door. Administrator provided directions telephonically and staff locked the door during the visit.

OUTDOOR AREA: The backyard has a covered outdoor area equipped with furniture for resident use. There were no bodies of water on the premises. There is a self-latching gate on the side of the house designated for an emergency exit. Passageways were free and clear from obstruction. At 10:34AM, LPA observed an unlocked and accessible shed containing cleaning solutions and detergents. Staff locked the shed during the visit. LPA observed a second shed that was locked and inaccessible containing additional supplies.
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: 05/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2025
LIC809 (FAS) - (06/04)
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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: FALLBROOK ELDERLY CARE LLC
FACILITY NUMBER: 195850252
VISIT DATE: 05/06/2025
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MEDICATION REVIEW: At 11:13AM, LPA reviewed medications for two (2) residents. Medications are centrally stored and locked in the hallway closet. All medications including PRNs were labeled, stored, and locked inaccessible to residents. PRNs were properly documented and logged. At 11:23AM, LPA observed Aspirin 81mg for Resident #1 (R1) missing two (2) pills that were unaccounted for. The medication is to be taken once a day and was started on 04/07/2025 with a quantity of thirty-one (31) pills, meaning that the medication should finish on 05/08/2025. However, the medication was fully finished with no documentation for the two (2) missing pills. At 11:41AM, LPA observed two (2) medications (Trazadone 50mg and Levothyroxine) missing start dates on the centrally stored medications and destruction record.


RECORD REVIEW: Beginning at 02:28PM, LPA reviewed five (5) out of five (5) resident files and four (4) personnel files for documents including but not limited to: medical records, care plans, resident Admission Agreement, TB test, health screening, staff training, first aid certification, and fingerprint clearance. LPA observed two (2) resident files missing PRN authorization letters and consent forms. LPA observed one (1) resident without a half rail order and one (1) resident with full rails but not receiving hospice services. Administrator will obtain PRN authorization letters and half rail order and will amend the full rail order to half rails if the resident does not begin hospice services. LPA observed one (1) staff without fingerprint clearance. Administrator stated Staff #1 (S1) will obtain a live scan by tomorrow 05/07/2025.

INFECTION CONTROL/EMERGENCY DISASTER PLANNING: During today’s visit, the LPA reviewed the facility's infection control policy and emergency disaster plan. Emergency disaster plan is updated annually as required and emergency disaster drills are conducted quarterly as is required, with the last drill conducted on 03/10/2025. All documents reviewed were updated and in compliance.

The following deficiencies were observed (See LIC 809-D) and cited from the California Code of Regulations, Title 22. Civil penalties were issued in the amount of $1000. Administrator was informed that failure to correct deficiencies may result in additional civil penalties.

Exit interview was conducted. A copy of the report and appeal rights were provided.

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

DATE: 05/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2025
LIC809 (FAS) - (06/04)
Page: 4 of 11
Document Has Been Signed on 05/06/2025 04:42 PM - It Cannot Be Edited


Created By: Angela Barutyan On 05/06/2025 at 03:55 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: FALLBROOK ELDERLY CARE LLC
FACILITY NUMBER: 195850252

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/06/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87202(a)
Fire Clearance
(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above as one (1) smoke detector was observed disconnected and fire extinguishers were expired which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/07/2025
Plan of Correction
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Administrator stated they will purchase and install new smoke detector and will either provide proof of scheduled fire extinguisher servicing or purchase a new fire extinguisher. Administrator will submit proof to CCL by 05/07/2025.
Type A
Section Cited
CCR
87309(a)
Storage Space and Access
(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above as detergents and cleaning solutions were accessible in the unlocked laundry area and outdoor storage shed which posed an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/07/2025
Plan of Correction
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Staff locked the laundry area and outdoor shed during the visit. Administrator stated that detergents will be kept locked and inaccessible. POC is cleared.
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: 05/06/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/06/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/06/2025 04:42 PM - It Cannot Be Edited


Created By: Angela Barutyan On 05/06/2025 at 03:55 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: FALLBROOK ELDERLY CARE LLC
FACILITY NUMBER: 195850252

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/06/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87355(e)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above as Staff #1 (S1) was missing criminal record clearance which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/07/2025
Plan of Correction
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Administrator stated S1 will obtain a live scan and submit proof to CCL by 05/07/2025.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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4
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: 05/06/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/06/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/06/2025 04:42 PM - It Cannot Be Edited


Created By: Angela Barutyan On 05/06/2025 at 04:05 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: FALLBROOK ELDERLY CARE LLC
FACILITY NUMBER: 195850252

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/06/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(h)(4)
87465(h)(4) 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. No persons other than the dispensing pharmacist shall alter a prescription label.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on medication review, the licensee did not comply with the section cited above as two (2) medications were not properly logged and one (1) medication had missing pills which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/13/2025
Plan of Correction
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Administrator logged the start dates for the medications with missing information. Administrator agreed to submit a signed statement of understanding of the section to CCL by 05/13/2025 and stated that additional medication training will be provided to staff in the near future.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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4
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: 05/06/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/06/2025


LIC809 (FAS) - (06/04)
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