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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195850285
Report Date: 01/29/2026
Date Signed: 01/29/2026 04:15:22 PM

Document Has Been Signed on 01/29/2026 04:15 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 ASSISTED LIVINGFACILITY NUMBER:
195850285
ADMINISTRATOR/
DIRECTOR:		ASATRYAN, YULIYAFACILITY TYPE:
740
ADDRESS:5504 FALLBROOK AVENUETELEPHONE:
(818) 713-0447
CITY:WOODLAND HILLSSTATE: CAZIP CODE:
91367
CAPACITY: 6CENSUS: 6DATE:
01/29/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:37 AM
MET WITH:Yuliya Asatryan - AdministratorTIME VISIT/
INSPECTION COMPLETED:
04:25 PM
NARRATIVE
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Licensing Program Analyst (LPA) Quoc Huynh arrived at the facility unannounced to conduct a required annual visit at 10:37AM. The LPA met with Administrator Yuliya Asatryan who arrived at 11:19AM. Entrance interview conducted.

Beginning at 11:20AM, the LPA and Administrator 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. The following was observed:

COMMON AREAS: At the time of the visit, two (2) living room and dining room furniture were observed to be in good condition. The LPA observed staff personal belongings in the dining room which included a medication bottle and pill organizer that was accessible to residents. The staff secured the items. Required postings were observed on the walls. The facility maintained a comfortable temperature throughout the visit. The first living room had a screened fireplace. There was a laundry area with secured cabinets containing cleaning supplies and detergent.

KITCHEN: The LPA observed knives and cleaning supplies secured. Kitchen appliances were clean and in operable condition. The facility had a supply of perishable food and non-perishable food supply was not sufficient for seven (7) days. Food in the refrigerator and freezer were observed to be properly stored with labels and dates. The kitchen also contained centrally stored medications. There were two (2) cabinets and one (1) drawer that contained medications and only one (1) cabinet was secured. The Administrator stated they didn’t know the additional medication needed to be secured.

Report Continued on LIC 809-C
NAME OF LICENSING PROGRAM MANAGER: Kristin Heffernan
NAME OF LICENSING PROGRAM ANALYST: Quoc Huynh
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 01/29/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/29/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 14
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)
Page: 2 of 14
Document Has Been Signed on 01/29/2026 04:15 PM - It Cannot Be Edited


Created By: Quoc Huynh On 01/29/2026 at 03:02 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 ASSISTED LIVING
FACILITY NUMBER: 195850285

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/29/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1569.618(c)(4)
Other Provisions
(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (4) Ensure that the facility is clean, safe, sanitary, and in good repair at all times.

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 in had personal items including medications accessible to residents which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/29/2026
Plan of Correction
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The Staff secured their items and medications during the visit. POC Cleared.
Type A
Section Cited
CCR
87465(h)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above in medication count and administration was not consistent or maintained which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/30/2026
Plan of Correction
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The Licensee will provide staff with medication training and provide CCLD proof by POC due date.
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:
Quoc Huynh
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 01/29/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/29/2026


LIC809 (FAS) - (06/04)
Page: 3 of 14
Document Has Been Signed on 01/29/2026 04:15 PM - It Cannot Be Edited


Created By: Quoc Huynh On 01/29/2026 at 03:02 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 ASSISTED LIVING
FACILITY NUMBER: 195850285

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/29/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(2)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

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 in medications were not secured which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/30/2026
Plan of Correction
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The Licensee will install locks to secure centrally stored medications and send CCLD proof by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:
Quoc Huynh
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 01/29/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/29/2026


LIC809 (FAS) - (06/04)
Page: 4 of 14
Document Has Been Signed on 01/29/2026 04:15 PM - It Cannot Be Edited


Created By: Quoc Huynh On 01/29/2026 at 03:02 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 ASSISTED LIVING
FACILITY NUMBER: 195850285

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/29/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(g)
Personnel Records
(g) All personnel records shall be maintained at the 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 in staff did not have health screening and TB test on file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/06/2026
Plan of Correction
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The Licensee will obtain the staff's health screening and TB tests and send CCLD proof by POC due date.
Type B
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above in staff annual training did not meet required topics and hours which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/13/2026
Plan of Correction
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The Licensee will review training requirements and create an annual training schedule and send CCLD proof by POC due date.
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:
Quoc Huynh
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 01/29/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/29/2026


LIC809 (FAS) - (06/04)
Page: 5 of 14
Document Has Been Signed on 01/29/2026 04:15 PM - It Cannot Be Edited


Created By: Quoc Huynh On 01/29/2026 at 03:02 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 ASSISTED LIVING
FACILITY NUMBER: 195850285

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/29/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87555(b)(26)
General Food Service Requirements
(b) The following food service requirements shall apply: (26) Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises.

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 in the facility's non-perishable food was not supplied for 7 days which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/02/2026
Plan of Correction
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The Licensee will obtain more non-perishable food and send CCLD proof by POC due date.
Type B
Section Cited
CCR
87506(a)
Resident Records
(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff.

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 in resident files were incomplete and not maintained which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/20/2026
Plan of Correction
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The Licensee will complete all resident files, obtain updated Physician's Report and Appraisals, and send CCLD proof by POC due date.
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:
Quoc Huynh
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 01/29/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/29/2026


LIC809 (FAS) - (06/04)
Page: 6 of 14
Document Has Been Signed on 01/29/2026 04:15 PM - It Cannot Be Edited


Created By: Quoc Huynh On 01/29/2026 at 03:02 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 ASSISTED LIVING
FACILITY NUMBER: 195850285

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/29/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87456(a)(2)
Evaluation of Suitability for Admission
(a) Prior to accepting a resident for care and in order to evaluate his/her suitability, the facility shall, as specified in this article 8: (2) Perform a pre-admission appraisal.

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 in 1 resident did not have a pre-admission appraisal conducted which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/06/2026
Plan of Correction
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The Licensee will review regulation and submit a statement of understanding by POC due date.
Type B
Section Cited
HSC
1569.695(a)(2)
Other Provisions
(a)In addition to any other requirement of this chapter, a residential care facility for the elderly shall have an emergency and disaster plan that shall include, but not be limited to, all of the following: (2) Plans for the facility to be self-reliant for a period of not less than 72 hours immediately following any emergency or disaster, including, but not limited to, a short-term or long-term power failure. If the facility plans to shelter in place and one or more utilities, including water, sewer, gas, or electricity, is not available, the facility shall have a plan and supplies available to provide alternative resources during an outage.

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 in the emergency food supply had expired items which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/06/2026
Plan of Correction
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The Licensee will discard of expired items and replenish emergency food. The Licensee will also come up with a schedule to review foods supply and send CCLD proof by POC due date.
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:
Quoc Huynh
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 01/29/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/29/2026


LIC809 (FAS) - (06/04)
Page: 7 of 14
Document Has Been Signed on 01/29/2026 04:15 PM - It Cannot Be Edited


Created By: Quoc Huynh On 01/29/2026 at 03:02 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 ASSISTED LIVING
FACILITY NUMBER: 195850285

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/29/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on record review, the licensee did not comply with the section cited above in emergency drills are not conducted quarterly which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/13/2026
Plan of Correction
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The Licensee will create an emergency drill schedule and send CCLD proof by POC due date.
Type B
Section Cited
CCR
87465(i)
(i) Prescription medications which are not taken with the resident upon termination of services, not returned to the issuing pharmacy, nor retained in the facility as ordered by the resident’s physician and documented in the resident’s record nor disposed of according to the hospice’s established procedures or which are otherwise to be disposed of shall be destroyed in the facility by the facility administrator and one other adult who is not a resident. Both shall sign a record, to be retained for at least three years, which lists the following:

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 in a prior resident's medications were not destroyed which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/01/2026
Plan of Correction
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The Licensee will have the former resident's family pick up the medications within 48 hours or discard it. The Licensee will send CCLD proof of desctruction record by POC due date.
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:
Quoc Huynh
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 01/29/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/29/2026


LIC809 (FAS) - (06/04)
Page: 8 of 14
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 ASSISTED LIVING
FACILITY NUMBER: 195850285
VISIT DATE: 01/29/2026
NARRATIVE
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BEDROOMS/RESTROOMS: There were six (6) total bedrooms: four (4) private resident rooms, one (1) shared resident room, and one (1) secured staff room. Each resident bedroom had a direct exit to the outside with the facility approved for one (1) bedridden resident. Bedrooms were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. Extra linens and supplies were stored in the hallway closet. There were two (2) total restrooms in the facility, both shared restrooms located in the hallways. One (1) restroom contained secured staff hygiene products. Restrooms were clean and sanitary and in operating condition with grab bars and non-slip surfaces. All restrooms were sufficiently stocked with soap, paper products, and displayed hand washing signs. Hot water was tested and measured between 105.8 degrees F and 111.4 degrees F which is within the required range per regulation.

OUTDOOR AREA: The surrounding grounds had multiple shaded patio areas equipped with furniture in good condition for resident and visitor use. There were two (2) emergency exit gates located on each side of the facility. Exits and passageways were free of obstruction. There was a gated driveway/carport that contained general storage and a shed. The LPA observed an accessible bag of medications belonging to a prior resident that was not destroyed. The Administrator stated the family planned to pick it up; however, has continued to push the date back. There was a cabinet that contained emergency food that the LPA observed to have expired canned and bottled items ranging between 2024 to 2025.

RECORDS: Record review began at 12:03PM. Resident records were reviewed for, but not limited to care plans, physician's report, admissions agreement, and consent forms. Resident #1 (R1) and Resident #2 (R2) had incomplete files and R1 was admitted on 01/17/2026 and did not complete a Pre-Admission Appraisal. Three (3) residents did not have updated Appraisals, and two (2) residents did not have updated Physician’s Reports. Personnel records were reviewed for, but not limited to health assessments, criminal record clearances, first aid/CPR training, and the appropriate training.

Report Continued on LIC 809-C
NAME OF LICENSING PROGRAM MANAGER: Kristin Heffernan
NAME OF LICENSING PROGRAM ANALYST: Quoc Huynh
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 01/29/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2026
LIC809 (FAS) - (06/04)
Page: 13 of 14
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 ASSISTED LIVING
FACILITY NUMBER: 195850285
VISIT DATE: 01/29/2026
NARRATIVE
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 One (1) staff did not have a health screening on file, and two (2) staff did not have a TB test on file. Staff annual training included two (2) hours of dementia and six (6) hours of medication with no training on postural support or restricted health conditions. The Administrator did not have knowledge of training requirements.

INFECTION CONTROL/EMERGENCY DISASTER PLAN: During today's visit, LPA reviewed the facility's infection control plan and emergency disaster plan. Both documents were observed to be complete and were not reviewed annually as required. Fire extinguishers were observed throughout the facility and were last serviced on 03/24/2025. Emergency disaster drills are not conducted quarterly, with the last documented drill on 09/09/2025. Smoke and carbon monoxide detectors were tested at 1:15PM and were operational.

MEDICATIONS: Medication review began at 1:31PM. Medications were centrally stored in the kitchen. Medications were observed for two (2) residents. R2 was prescribed Quetiapine Fumarate and instructed one (1) tab twice daily. The medication started on 01/01/2026 and had nine (9) tabs extra. The staff and Administrator stated R2 refused on one (1) occasion; however, there were no records of refusal. Resident #3 (R3) was prescribed Metoprolol and Magnesium Oxide and both instructed one (1) tab daily. Both medications started on 01/13/2026 and each had one (1) tab extra. The LPA observed the facility prepared medications two (2) days in advance and stated they can no longer do so per regulation. The Administrator disagreed with the regulation and stated that it would cause medication errors due to multiple staff handling medications.

Pursuant to Title 22 CA Code of Regulations and/or the Health and Safety Code, the following deficiencies were cited (Refer to LIC 809-D).

Exit interview conducted. A copy of the appeal rights and report was reviewed and provided.
NAME OF LICENSING PROGRAM MANAGER: Kristin Heffernan
NAME OF LICENSING PROGRAM ANALYST: Quoc Huynh
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 01/29/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2026
LIC809 (FAS) - (06/04)
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