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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197602257
Report Date: 02/24/2026
Date Signed: 02/24/2026 03:45:19 PM

Document Has Been Signed on 02/24/2026 03:45 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 S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:MARBLE TERRACE IIFACILITY NUMBER:
197602257
ADMINISTRATOR/
DIRECTOR:		GODLEWSKA, ELIZABETHFACILITY TYPE:
740
ADDRESS:19030 MIRANDA AVENUETELEPHONE:
(818) 345-8971
CITY:TARZANASTATE: CAZIP CODE:
91356
CAPACITY: 6CENSUS: 5DATE:
02/24/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:55 PM
MET WITH:Bozena KozbialTIME VISIT/
INSPECTION COMPLETED:
04:00 PM
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At approximately 12:55 p.m. on 02/24/26, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced annual inspection. LPA met with the administrator and disclosed the reason for the visit.

A file review was conducted prior to the visit.

The facility was last visited on 02/05/25 for an annual inspection. It is a single story building with six (06) bedrooms, four (04) bathrooms, kitchen, garage, common areas, and outdoor areas. It has an approved fire clearance for six (06) nonambulatory residents. Approved hospice waivers for six (06).

At the main entrance, LPA observed a maintained front yard with stairs leading to the unlocked main entrance. The driveway was free of debris. Postings were observed for confidential complaint contacts, ombudsman contacts, personal rights, rights of resident councils, nondiscrimination notice, neighborhood grievance procedure, emergency disaster plan, facility license, facility sketch, administrator certificate, and a blank copy of an admission agreement. A sign showing “No smoking – Oxygen in use” was posted at the main entrance.

Walls, floors, windows, screens, and blinds were clean and in good repair. The living room contained furniture in good repair, reading material, puzzles, art supplies, and exercise equipment. An office was locked and contained confidential files and medications. A linen closet near Bedroom #4 contained an adequate supply of fresh linens, PPE, and hygiene supplies. A locked closet near the office contained medications and a fully stoked first aid kit. Four (04) out of four (04) auditory alarms were tested and functional. LPA observed a covered patio area in the rear of the facility. At approximately 1:15 p.m. the room temperature to be 76 degrees Fahrenheit.

NAME OF LICENSING PROGRAM MANAGER: Naira Margaryan
NAME OF LICENSING PROGRAM ANALYST: Nicholas Reed
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 02/24/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/24/2026
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 S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: MARBLE TERRACE II
FACILITY NUMBER: 197602257
VISIT DATE: 02/24/2026
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The facility has six (06) bedrooms. Bedroom #6 is designated as a staff room. The staff room was free of hazards. All bedrooms contained a chair, lamp, nightstand, storage, and a bed with adequate bedding. All furnishings were clean and in good condition. All beds with wheels were maintained in the locked position.

The facility has four (04) bathrooms. One (01) bathroom is designated for staff, and three (03) others are shared for residents. All bathrooms contained liquid soap, paper towels, trash cans, grab bars near the toilet and shower, and a non-skid mat or non-skid surfaces in the showers. At 1:25 p.m. LPA measured the water temperature in the bathroom near Bedroom #5 to be 108.5 degrees Fahrenheit. At approximately 1:40 p.m., smoke and carbon monoxide detectors were tested and operational. Two (02) out of two (02) smoke alarms were hard-wired and functioned simultaneously.

LPA observed an adequate supply of perishable and non-perishable foods in the kitchen refrigerator and freezer. A pantry near Bedroom #3 contained additional non-perishable food supplies. The stove hood was clean. Appliances were in good condition. Sharps were locked below the stove. Cleaning solutions were locked below the sink. A washing machine and dryer were located adjacent to the kitchen. Both were in working order. Detergents were locked above the washer. At 1:50 p.m. LPA observed a fully charged fire extinguisher in the kitchen. It was last inspected on 05/16/25 with a tag attached. LPA called out from the house telephone at 1:55 p.m. and was deemed operational.

All emergency exit paths were free from obstructions. Two (02) out of two (02) exit gates were unlocked. The garage was unlocked and free of hazards. The patio contained furniture in good condition.

At 2:10 p.m., LPA reviewed resident and personnel files. All files were complete and available for audit. Additionally, LPA reviewed the updated certificate of liability insurance which expires 07/03/26.

During today’s inspection, no immediate health and safety risks were observed.

Exit interview conducted. Copy of report provided.

NAME OF LICENSING PROGRAM MANAGER: Naira Margaryan
NAME OF LICENSING PROGRAM ANALYST: Nicholas Reed
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 02/24/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2026
LIC809 (FAS) - (06/04)
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