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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195850631
Report Date: 06/10/2025
Date Signed: 06/10/2025 11:38:25 AM

Document Has Been Signed on 06/10/2025 11:38 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:MARYANN CARE HOME LLCFACILITY NUMBER:
195850631
ADMINISTRATOR/
DIRECTOR:		HOWE, MARY ANNFACILITY TYPE:
740
ADDRESS:5523 FALLBROOK AVENUETELEPHONE:
(818) 914-4748
CITY:WOODLAND HILLSSTATE: CAZIP CODE:
91367
CAPACITY: 6CENSUS: 0DATE:
06/10/2025
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:32 AM
MET WITH:Mary Ann HoweTIME VISIT/
INSPECTION COMPLETED:
11:50 AM
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Licensing Program Analyst (LPA) Angela Barutyan conducted a pre-licensing visit to the facility noted above at 10:32AM. LPA met with Applicant Mary Ann Howe. The applicant has obtained fire clearance for a total capacity of six (6) residents.

LPA inspected facility for Fire Safety, Personal Accommodations and Services, and Food Service. The facility is a single-story home. The facility has three (3) resident bedrooms for shared-use. All resident bedrooms are cleared for non-ambulatory. The hard-wired smoke alarms and carbon monoxide detectors were tested and function properly. LPA observed fire extinguisher to be fully charged and last serviced 07/17/2024.

LPA toured the kitchen area at approximately 10:35AM. At 10:37AM, hot water temperature was measured in the kitchen sink and was 121.2 degrees F. Water heater was lowered during the visit. LPA remeasured hot water at 10:48AM and measured at 110.1 degrees F. Appliances and all equipment appeared to be clean and in good repair. The kitchen has a sufficient supply of plates, cups, cookware, and utensils. Knives, sharps, and cleaning solutions were locked in a cabinet under the sink. LPA observed emergency food and water supply in the kitchen.

Resident bedrooms are equipped with clean mattresses, pillows, and bedding. Bedrooms have sufficient lighting. There is a sufficient supply of linens, including blankets, bath towels and wash cloths. LPA observed Bedroom #3 with direct exit to the exterior and an adequately screened fireplace. The facility has two (2) bathrooms located in the hallway. One (1) is for resident and visitor use and one (1) is for staff use. Bathrooms contained appropriate slip-resistant surfaces and grab bars. Hot water temperature was measured in bathrooms and were between 107.5-108.1 degrees F, which is within the required range.

Report Continued on LIC 809C...

NAME OF LICENSING PROGRAM MANAGER: Kristin Heffernan
NAME OF LICENSING PROGRAM ANALYST: Angela Barutyan
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 06/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/10/2025
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: MARYANN CARE HOME LLC
FACILITY NUMBER: 195850631
VISIT DATE: 06/10/2025
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Report Continued from LIC 809C...

The living areas and dining areas are clean and properly furnished. All window screens and coverings are in good repair. LPA observed enough seating for six (6) residents at the same time. A working telephone is present. There are activity supplies. There is one (1) fireplace in the living room and was observed adequately screened. Night-lights were present in the hallways. Medications will be stored and locked in a closet by the living room. LPA observed a complete first aid kit in the medication closet. Facility records will be kept in a cabinet in the living room.

Additional cleaning supplies, toxins, a washer and dryer, detergents, and disinfectants were observed in the detached garage which is kept locked. There will be no firearms/ammunition stored on the property. The facility has required postings, including Emergency Exit Plan, Resident Personal Rights, and Theft and Loss Policy.

Outdoor passageways were free of obstructions. There are no bodies of water on the premises at the time of the visit. LPA observed an outdoor area with a table and chairs for client use. All exits had functioning auditory exit alarms.

Physical plant is consistent with the submitted facility sketch/floor plan.

Comp III conducted with Applicant.

Pre-Licensing is complete and this facility has no deficiencies.

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 conducted. The report was reviewed, and a copy was provided.

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

DATE: 06/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/10/2025
LIC809 (FAS) - (06/04)
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