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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195850562
Report Date: 12/10/2024
Date Signed: 12/10/2024 10:25:47 AM

Document Has Been Signed on 12/10/2024 10:25 AM - 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:A'ONE VILLA ASSISTED LIVINGFACILITY NUMBER:
195850562
ADMINISTRATOR/
DIRECTOR:
SINGH, JAGDEEPFACILITY TYPE:
740
ADDRESS:23511 BERDON STREETTELEPHONE:
(818) 704-0012
CITY:WOODLAND HILLSSTATE: CAZIP CODE:
91367
CAPACITY: 6CENSUS: 0DATE:
12/10/2024
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:15 AM
MET WITH:Jagdeep SinghTIME VISIT/
INSPECTION COMPLETED:
10:45 AM
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On 12/10/2024, Licensing Program Analyst (LPA) Angela Barutyan conducted a subsequent pre-licensing visit. The LPA arrived at the facility at 10:15AM and met with Applicant Jagdeep Singh. This is a new facility application for a Residential Care Facility for the Elderly (RCFE).

On 11/26/2024, the initial pre-licensing visit was conducted by LPA Barutyan. The LPA arrived at the facility and met with Applicant Jagdeep Singh and Applicant Representative Ravleen Kaur. The LPA, and the applicant 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. This is a new facility application for a Residential Care Facility for the Elderly (RCFE). Fire Clearance was approved on 10/21/2024 and all six (6) bedrooms are cleared for bedridden. The applicant has obtained fire clearance for a total capacity of six (6) residents.

At 10:15AM, the LPA and the Applicant toured the facility to ensure the corrections were completed. Pre-Licensing deficiencies have been resolved. Pre-Licensing is now complete.



This report will be sent to the Centralized Application Bureau (CAB). You will be notified by the CAB Analyst when your license has been approved. You are not allowed to begin operating until you have been notified that your license has been approved by the CAB Analyst. Failure to comply could affect approval of your license.

Exit interview was conducted and reviewed with applicant. A copy of the report was issued.

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Angela Barutyan
LICENSING EVALUATOR SIGNATURE: DATE: 12/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/10/2024
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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