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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195850533
Report Date: 12/22/2025
Date Signed: 12/22/2025 05:56:17 PM

Document Has Been Signed on 12/22/2025 05:56 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:BLYTHE SENIOR ASSISTED LIVINGFACILITY NUMBER:
195850533
ADMINISTRATOR/
DIRECTOR:		MURADYAN, ARAMFACILITY TYPE:
740
ADDRESS:13030 BLYTHE STTELEPHONE:
(818) 818-8005
CITY:NORTH HOLLYWOODSTATE: CAZIP CODE:
91605
CAPACITY: 6CENSUS: 6DATE:
12/22/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:01 AM
MET WITH:Aram MuradyanTIME VISIT/
INSPECTION COMPLETED:
06:15 PM
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Licensing Program Analyst (LPA) Trevor Byrne arrived at the facility unannounced to conduct the required annual visit at 10:01 AM. LPA met with facility staff who contacted the facility Administrator Aram Muradyan. The Administrator arrived to the facility at 10:13 AM. Entrance interview was conducted and the reason for the visit was explained.
Beginning at 10:14 AM the LPA, along with the Administrator toured the physical plant areas inside and outside to ensure there are no health and safety hazards and that facility is in compliance with Title 22 Regulations. The following was observed:

BEDROOMS: There are four (4) bedrooms in the facility; two (2) are dual occupancy resident rooms, two (2) are single occupancy resident rooms. LPA and the facility Administrator toured all four (4) bedrooms. All resident rooms were observed to be furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting. Bedrooms #1 and 4 contained direct exits to the outdoors of the facility. LPA observed the auditory alarms in bedroom#1 and 4 to be non-functional at the time of the visit. LPA informed the Administrator who agreed to replace/repair the auditory alarms.

OUTDOOR SPACE: The facility has one (1) emergency exit gate located on the side of the facility; LPA observed clear passageways for emergency exit use. The facility had adequate shaded seating outdoors for resident use. LPA observed the outdoors of the facility to contain a properly secured swimming pool and a small fountain. LPA observed an appropriately secured washer/dryer room which contained the facility’s washer and dryer, cleaning chemicals, extra care supplies, a sink, and a toilet. LPA observed the outdoors of the facility to contain unsecured spray paint, lighter fluid, bug spray, and paint cans. LPA informed the Administrator who agreed to secure the items in a locked storage. Continued on LIC 809C.
NAME OF LICENSING PROGRAM MANAGER: Kasandra Lopez
NAME OF LICENSING PROGRAM ANALYST: Trevor Byrne
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 12/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/22/2025
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: BLYTHE SENIOR ASSISTED LIVING
FACILITY NUMBER: 195850533
VISIT DATE: 12/22/2025
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COMMON AREAS: This included the living room, hallway, and dining area. LPA observed the living room to be clean and properly furnished at the time of the visit. The living room contained a television, adequate seating, and an appropriately screened fireplace. The hallway was observed to be clean and free from any obstructions. The hallway contained closets that contained storage for linens and care supplies. LPA observed a hallway closet to contain an unsecured bottle of disinfectant spray. LPA informed the Administrator who immediately secured the bottle in appropriate storage. The dining area was observed to be equipped with adequate seating for resident use and contained locked storage for resident medications and files. LPA observed the dining area to contain a wall mounted fire extinguisher that was fully charged and purchased on 11/12/2024 which was more than twelve (12) months from the inspection date. LPA informed the Administrator who agreed to purchase a new fire extinguisher for the facility. The common areas contained all required postings. LPA observed RING cameras equipped with a microphone in the dining room and living room. LPA reviewed the admission agreements of facility residents which stated “Under no circumstances video surveillance will be permitted or utilized at Blythe assisted living.” LPA informed the Administrator that utilization of the cameras posed a personal rights risk to the clients due to the resident’s admission agreements and due to the auditory recording component of the cameras. The Administrator expressed understanding and removed the cameras from the facility at the time of the visit. The facility’s fire and carbon monoxide alarms were tested between 10:47 AM and 10:58 AM LPA observed three (3) fire alarms in the living room, dining area, and hallway that were not plugged in via hardwire or equipped with batteries. LPA informed the Administrator that fire alarms must be maintained in proper working order and not having the fire alarms in a function state poses an immediate safety risk to clients in care and violates the facility’s fire clearance. LPA informed the Administrator that this is a zero-tolerance violation and an immediate civil penalty of $500 is being assessed on today’s date (12/22/2025) for a violation of the facility’s fire clearance. The Administrator expressed understanding and immediately plugged the three (3) fire alarms into the hardwire. Additionally, the Administrator replaced the batteries in the three identified fire alarms at the time of the visit.

Continued on LIC 809C.
NAME OF LICENSING PROGRAM MANAGER: Kasandra Lopez
NAME OF LICENSING PROGRAM ANALYST: Trevor Byrne
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2025
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: BLYTHE SENIOR ASSISTED LIVING
FACILITY NUMBER: 195850533
VISIT DATE: 12/22/2025
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KITCHEN: The LPA observed the kitchen area to be clean. Kitchen appliances appeared to be in operable condition. The facility had a sufficient supply of two (2) days perishable and seven (7) days non-perishable food. LPA observed an under-sink cabinet to contain cleaning chemicals and drawers to contain knives and other sharp objects. LPA observed these cabinets and drawers to be unsecured with no staff member working in the kitchen. LPA informed the Administrator who stated that staff had stepped out of the kitchen for a moment. LPA informed the Administrator that knives, sharp objects, and chemicals must remain secured if not in use by a staff member. The Administrator expressed understanding and secured the drawers/cabinet at the time of the visit.

BATHROOMS: There are three (3) bathrooms at the facility. One is designated as a shared/common resident bathroom, one (1) is a private resident bathroom, and one (1) is a staff bathroom/laundry room. Both resident bathrooms were observed to be clean and were equipped with nonskid surfaces. Grab bars were observed in all resident showers and near all resident toilets, all were properly secured. The water temperature was measured to be between 117.0 and 118.2 degrees Fahrenheit, which is in compliance with regulation.

RECORD REVIEW: Record review began at 11:05 PM. Staff and resident records were reviewed for documents including, but not limited to: health screening, TB test, staff training records, fingerprint clearance, resident physician's report, needs and service appraisal, consent forms, and personal rights. three (3) staff files were reviewed. No staff files reviewed contained records of the initial forty (40) hours of training required prior to assisting residents. LPA requested to review a staff file for Staff #1 (S1) but was unable due to the file not being present at the facility. LPA reviewed the Administrator’s staff file which was observed to be missing the LIC 501, LIC 508, LIC 503, and proof of a negative TB test. Six (6) resident files were reviewed. Resident #1 (R1), Resident #2 (R2), and Resident #3 (R3)’s files were observed to be missing signed copies of the resident’s personal rights. R1’s file was observed to be missing a copy of their admission agreement. R2’s file was observed to be missing a signed telecommunication device notification and R2 was identified by their physician to have an auditory impairment. Additionally, Resident #4 (R4), Resident #5 (R5), and Resident #6 (R6)’s files were observed to be missing proof of a negative Tuberculosis (TB) test. LPA informed the Administrator of the missing documents and that files must be maintained at the facility. The Administrator expressed understanding and agreed to complete all required documentation and trainings for staff and resident files. Continued on LIC 809C.
NAME OF LICENSING PROGRAM MANAGER: Kasandra Lopez
NAME OF LICENSING PROGRAM ANALYST: Trevor Byrne
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2025
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: BLYTHE SENIOR ASSISTED LIVING
FACILITY NUMBER: 195850533
VISIT DATE: 12/22/2025
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MEDICATION REVIEW: Medication review began at approximately 01:00 PM. Medications for three (3) of six (6) residents were observed. All medications were stored properly. No medications observed were documented on their respective centrally stored medication and destruction record sheets (CSMDR). LPA informed the Administrator that a log of the medications that residents are taking must be accurate and maintained at the facility. LPA informed the Administrator that the log must include: the name of the resident for whom the medication is prescribed, the name of the prescribing physician, the drug name, strength and quantity, the date filled, the prescription number and the name of the issuing pharmacy, and instructions, if any, regarding control and custody of the medication. LPA informed the Administrator that for every prescription and nonprescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician, on a prescription blank, maintained in the residents file, and a label on the medication in addition to the CSMDR. The Administrator expressed understanding and agreed to complete a CSMDR for all facility residents.

INFECTION CONTROL/EMERGENCY DISASTER PLANNING: During today’s visit, the LPA reviewed the
facility's infection control practices and the facility's emergency disaster plan. The facility’s policies and procedures as they pertain to infection control are adequate. Emergency disaster drills are to be conducted quarterly; LPA asked the Administrator when the facility’s last emergency disaster drill was conducted. The Administrator informed LPA that the facility had not yet conducted an emergency disaster drill. LPA informed the Administrator that a facility shall conduct a disaster drill at least quarterly for each shift. The Administrator expressed understanding and agreed to conduct a disaster drill. The facility’s emergency disaster plan is up to date and is adequate. Both the infection control plan and the emergency disaster plan were not reviewed/updated annually by the facility’s Administrator. LPA informed the Administrator who reviewed both plans at the time of the visit.

INTERVIEWS: LPA interviewed two (2) residents. The residents interviewed stated that staff treat them well and are quick to respond when asked. No residents had concerns with the facility. LPA interviewed two (2) staff members. One (1) staff member interviewed was knowledgeable on their roles and responsibilities, the resident’s rights, the forms of abuse, and the appropriate reporting procedures for suspected abuse. One (1) staff member interviewed was unable to appropriately identify the resident’s rights but was knowledgeable on their roles and responsibilities, the different forms of abuse, and the appropriate reporting procedures for suspected abuse. Continued on LIC 809C.
NAME OF LICENSING PROGRAM MANAGER: Kasandra Lopez
NAME OF LICENSING PROGRAM ANALYST: Trevor Byrne
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2025
LIC809 (FAS) - (06/04)
Page: 5 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: BLYTHE SENIOR ASSISTED LIVING
FACILITY NUMBER: 195850533
VISIT DATE: 12/22/2025
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During today’s visit LPA obtained a copy of the facility’s LIC 500, resident roster, and current liability insurance.

Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited and civil penalty assessed (refer to LIC 809-D): Exit interview conducted and copy of the report was issued and appeal rights provided.

NAME OF LICENSING PROGRAM MANAGER: Kasandra Lopez
NAME OF LICENSING PROGRAM ANALYST: Trevor Byrne
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2025
LIC809 (FAS) - (06/04)
Page: 6 of 14
Document Has Been Signed on 12/22/2025 05:56 PM - It Cannot Be Edited


Created By: Trevor Byrne On 12/22/2025 at 04:24 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: BLYTHE SENIOR ASSISTED LIVING
FACILITY NUMBER: 195850533

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/22/2025

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, the licensee did not comply with the section cited above as three of the facility's fire alarms in the dining area, living room, and hallway were not hardwired and did not contain a battery rendering them non-functional. Additionally the fire extinguisher was purchased more than 12 months from the inspection date which poses an immediate safety risk to persons in care.
POC Due Date: 12/23/2025
Plan of Correction
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Administrator agreed to purchase a new fire extinguisher and to replace the batteries in all fire alarms and to ensure all fire alarms are hard wired. Administrator agreed to submit proof of correction no later than POC due date.
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 knives and under-sink cleaning chemicals in the kitchen, disinfectant spray in the hallway, and paints, lighter fluid, and bug spray were left unsecured in the outdoors of the facility which poses an immediate health and safety risk to persons in care.
POC Due Date: 12/23/2025
Plan of Correction
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Administrator agreed to secure the items and send proof to CCLD no later than 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.
Kasandra Lopez
NAME OF LICENSING PROGRAM MANAGER:
Trevor Byrne
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 12/22/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/22/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/22/2025 05:56 PM - It Cannot Be Edited


Created By: Trevor Byrne On 12/22/2025 at 04:24 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: BLYTHE SENIOR ASSISTED LIVING
FACILITY NUMBER: 195850533

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/22/2025

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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3
4
Based on record review, the licensee did not comply with the section cited above as the Administrator's and S1's records were not located at the facility at the time of the inspection which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/05/2026
Plan of Correction
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Administrator agreed to obtain the complete staff files for the identified individuals and submit proof of the completed files located at the facility to CCLD no later than POC due date.
Type B
Section Cited
CCR
87412(a)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:

This requirement is not met as evidenced by:
Deficient Practice Statement
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3
4
Based on record review, the licensee did not comply with the section cited above as the Administrator and S1's files were incomplete and were missing documentation including but not limited to LIC 501, 503, 508, TB test, trainings Etc. which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/05/2026
Plan of Correction
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Administrator agreed to submit the complete staff files for the identified individuals to CCLD no later than 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.
Kasandra Lopez
NAME OF LICENSING PROGRAM MANAGER:
Trevor Byrne
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 12/22/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/22/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/22/2025 05:56 PM - It Cannot Be Edited


Created By: Trevor Byrne On 12/22/2025 at 04:24 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: BLYTHE SENIOR ASSISTED LIVING
FACILITY NUMBER: 195850533

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/22/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.625(b)(1)
Other Provisions
(1) The department shall adopt regulations to require staff members of residential care facilities for the elderly who assist residents with personal activities of daily living to receive appropriate training. This training shall consist of 40 hours of training. A staff member shall complete 20 hours, including six hours specific to dementia care, as required by subdivision (a) of Section 1569.626 and four hours specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696, before working independently with residents. The remaining 20 hours shall include six hours specific to dementia care and shall be completed within the first four weeks of employment. The training coursework may utilize various methods of instruction, including, but not limited to, lectures, instructional videos, and interactive online courses. The additional 16 hours shall be hands-on training.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on interview and record review, the licensee did not comply with the section cited above as staff had not received the required 40 hours of initial training or the 20 hours of continuing training prior to working with residents which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/05/2026
Plan of Correction
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Administrator agreed to conduct the required trainings with staff members and will submit proof of the completed trainings to CCLD no later than 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.
Kasandra Lopez
NAME OF LICENSING PROGRAM MANAGER:
Trevor Byrne
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 12/22/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/22/2025


LIC809 (FAS) - (06/04)
Page: 9 of 14
Document Has Been Signed on 12/22/2025 05:56 PM - It Cannot Be Edited


Created By: Trevor Byrne On 12/22/2025 at 04:24 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: BLYTHE SENIOR ASSISTED LIVING
FACILITY NUMBER: 195850533

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/22/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87468(b)(1)(A)
Personal Rights of Residents
(b) At the time the admission agreement is signed, a resident and the resident's representative shall be personally advised of and given a copy of: (1) The personal rights of residents specified in Sections 87468.1, Personal Rights of Residents in All Facilities and 87468.2, Additional Personal Rights of Residents in Privately Operated Facilities, as applicable to the facility. (A) The licensee shall have each resident and the resident's representative sign a copy of these rights, and the signed copy shall be included in the resident's record.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above as three resident files did not contain a signed copy of the resident's rights which poses a potential personal rights risk to persons in care.
POC Due Date: 01/05/2026
Plan of Correction
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2
3
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Administrator agreed to obtain a signed copy of the resident's personal rights for the identified individuals and agreed to submit signed copies to CCLD no later than POC due date.
Type B
Section Cited
CCR
87465(e)
Incidental Medical and Dental Care Services
(e) For every prescription and nonprescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician on a prescription blank, maintained in the resident's file, and a label on the medication. Both the physician's order and the label shall contain at least all of the following information.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above as three resident medications and files observed did not contain up to date prescription information or physician's orders which poses a potential health risk to persons in care.
POC Due Date: 01/05/2026
Plan of Correction
1
2
3
4
Administrator agreed to obtain physician's orders for all resident medications and agreed to place copies of the prescription orders in the resident's files. Administrator agreed to submit proof of the up to date prescription orders to CCLD no later than 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.
Kasandra Lopez
NAME OF LICENSING PROGRAM MANAGER:
Trevor Byrne
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 12/22/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/22/2025


LIC809 (FAS) - (06/04)
Page: 10 of 14
Document Has Been Signed on 12/22/2025 05:56 PM - It Cannot Be Edited


Created By: Trevor Byrne On 12/22/2025 at 04:24 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: BLYTHE SENIOR ASSISTED LIVING
FACILITY NUMBER: 195850533

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/22/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87458(c)(1)(A)
Medical Assessment
(c) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the licensed medical professional's diagnosis or diagnoses and results of an examination for all of the following: (A) Communicable tuberculosis.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above as three residents did not have proof of a negative TB test located in their files which poses a potential health risk to persons in care.
POC Due Date: 01/05/2026
Plan of Correction
1
2
3
4
Administrator agreed to obtain a negative TB test for the identified individuals and agreed to submit proof of the negative TB tests to CCLD no later than POC due date.
Type B
Section Cited
CCR
87507(b)
Admission Agreements
(b) The licensee shall complete and maintain in the resident's file a Telecommunications Device Notification form (LIC 9158, 11/04) for each resident whose pre-admission appraisal or medical assessment indicates he/she is deaf, hearing-impaired, or otherwise disabled in accordance with Public Utilities Code sections 2881(a) and (c).

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above as one hearing impaired resident did not have a signed telecommunication device notification form located in their file which poses a potential personal rights risk to persons in care.
POC Due Date: 01/05/2026
Plan of Correction
1
2
3
4
Administrator agreed so complete the LIC 9158 form with the identified resident and agreed to submit proof of the completed form to CCLD no later than 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.
Kasandra Lopez
NAME OF LICENSING PROGRAM MANAGER:
Trevor Byrne
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 12/22/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/22/2025


LIC809 (FAS) - (06/04)
Page: 11 of 14
Document Has Been Signed on 12/22/2025 05:56 PM - It Cannot Be Edited


Created By: Trevor Byrne On 12/22/2025 at 04:24 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: BLYTHE SENIOR ASSISTED LIVING
FACILITY NUMBER: 195850533

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/22/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87507(c)
Admission Agreements
(c) Admission agreements shall be signed and dated, acknowledging the contents of the document, by the resident or the resident's representative, if any, and the licensee or the licensee's designated representative no later than seven days following admission. Attachments to the agreement may be utilized as long as they are also signed and dated as prescribed above.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above as one resident's file did not contain a completed admission agreement which poses a potential personal rights risk to persons in care.
POC Due Date: 01/05/2026
Plan of Correction
1
2
3
4
Administrator agreed to submit proof of the completed admission agreement for the identified individual to CCLD no later than POC due date.
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
1
2
3
4
Based on interview and record review, the licensee did not comply with the section cited above as the facility had not been conducting disaster drills which poses a potential safety risk to persons in care.
POC Due Date: 01/05/2026
Plan of Correction
1
2
3
4
Administrator agreed to conduct disaster drills quarterly. Administrator agreed to submit proof of a completed disaster drill to CCLD no later than 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.
Kasandra Lopez
NAME OF LICENSING PROGRAM MANAGER:
Trevor Byrne
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 12/22/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/22/2025


LIC809 (FAS) - (06/04)
Page: 12 of 14
Document Has Been Signed on 12/22/2025 05:56 PM - It Cannot Be Edited


Created By: Trevor Byrne On 12/22/2025 at 04:47 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: BLYTHE SENIOR ASSISTED LIVING
FACILITY NUMBER: 195850533

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/22/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87507(f)
87507 Admission Agreements
(f) The licensee shall comply with all applicable terms and conditions set forth in the admission agreement, including all modifications and attachments.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and record review, the licensee did not comply with the section cited above as the admission agreements that resident's signed stated, “Under no circumstances video surveillance will be permitted or utilized at Blythe assisted living.” while the facility had RING cameras installed in the dining room and living room of the facility which poses a potential personal rights risk to persons in care.
POC Due Date: 01/05/2026
Plan of Correction
1
2
3
4
Administrator removed the cameras at the time of the visit. Administrator agreed to submit a statement of understanding confirming that they would comply with all items of the admission agreement. Administrator agreed to submit the document no later than POC due date.
Type B
Section Cited
CCR
87465(h)(6)
87465 Incidental Medical and Dental Care
(h) The following requirements shall apply to medications which are centrally stored:
(6) The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least one year and includes:
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above as resident files did not contain an updated record of medications and were missing information including but not limited to: dosage, quantity, prescription numbers, date filled etc. which poses a potential health risk to persons in care.
POC Due Date: 01/05/2026
Plan of Correction
1
2
3
4
Administrator agreed to complete a CSMDR for all residents. Administrator agreed to submit proof of the completed CSMDRs to CCLD no later than 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.
Kasandra Lopez
NAME OF LICENSING PROGRAM MANAGER:
Trevor Byrne
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 12/22/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/22/2025


LIC809 (FAS) - (06/04)
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