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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197606694
Report Date: 08/27/2025
Date Signed: 08/27/2025 12:24:21 PM

Document Has Been Signed on 08/27/2025 12:24 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.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:DAISY ANNE GARDENSFACILITY NUMBER:
197606694
ADMINISTRATOR/
DIRECTOR:		ESTELA MONDERINFACILITY TYPE:
740
ADDRESS:20634 KITTRIDGE STREETTELEPHONE:
(818) 704-4338
CITY:WINNETKASTATE: CAZIP CODE:
91306
CAPACITY: 5CENSUS: 3DATE:
08/27/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:16 AM
MET WITH:Estela Monderin - AdministratorTIME VISIT/
INSPECTION COMPLETED:
12:30 PM
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On 8/27/2025 Licensing Program Analyst (LPA) Perchui Milena Khurshudyan arrived at this facility to conduct a required Annual Inspection. Upon arrival LPA was greeted by the Administrator Estela Monderin, who granted access to the facility. LPA introduced herself by showing her badge and explained the reason for the visit. LPA Khurshudyan reviewed the required postings on the hallway wall next to the kitchen area.

The inspection tool was used to complete the visit.

At 9:45am LPA jointly with the Administrator began a physical plant tour of the facility and the following was observed: This is a single-story building with four (4) bedrooms, all rooms designated for residents’ use and one staff bedroom designated for staff use only. There are two (2) bathrooms, kitchen, common areas: living and dining rooms, and outdoor areas. Facility has an approved fire clearance for five (5) Non-ambulatory residents. The facility also has a Hospice waiver for five (5) residents.

Common Areas: The facility maintains a comfortable temperature at 78°F. The living room and dining area appeared generally clean and were properly furnished. No obstructions and or tripping hazards throughout the facility were observed.

Kitchen: At approximately 10:20am LPA toured the kitchen area and observed enough supplies of non-perishable for minimum 1 week and perishable food for 2 days at the facility. Sharps/knives were properly stored and locked inside the kitchen cabinet. There is a fire extinguisher on the kitchen countertop, which was last serviced on 7/10/2025. Chemicals observed to be locked under the sink and inaccessible to residents in care.


Continue on LIC809-C
NAME OF LICENSING PROGRAM MANAGER: Nichelle Gillyard
NAME OF LICENSING PROGRAM ANALYST: Perchui Khurshudyan
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 08/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/27/2025
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 3
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.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: DAISY ANNE GARDENS
FACILITY NUMBER: 197606694
VISIT DATE: 08/27/2025
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Bathrooms: At 10:30am LPA observed all bathrooms are clean and in good repair. Properly supplied with toilet paper, soap and paper towels. The hot water temperature measured at 110.8°F. LPA observed appropriate grab bars and non-skid mats. All trash cans in bathrooms had fitted lids to protect from cross contamination.

Smoke detectors/carbon monoxide. Dual smoke and carbon monoxide detectors were located throughout the facility, and at 11:35am they were tested and observed to be operational.

Outside areas: At approximately 11:40am LPA toured the outside area of the facility and observed appropriate outdoor furniture, with a covered shaded area for residents. LPA discussed the importance of maintaining care and supervision to meet the needs of residents. There are no bodies of water.

Laundry Room: Laundry machines are placed outside of the property. Disinfectants, laundry detergents and hygiene supplies were stored and inaccessible to residents in care. Extra linens were stored in a separated linen closet and readily available.

Garage: There is no garage in the property.

Between 10:35am to 12:00pm, LPA reviewed records of three (3) residents and four (4) staff members. Resident and staff records appeared to be complete and updated.

MEDICATION: LPA observed centrally stored medication and First Aid kit locked inside the closet located in the hallway next to bathroom #1, and inaccessible to residents in care. LPA observed First-aid kit is complete and has new manual. Facility has a Dementia Care Program. PRN medications have written orders from a physician. The facility serves residents with dementia and the facility has trained staff to meet the needs of residents who are diagnosed with dementia. Facility has two (2) staff for AM shift and two (2) awake caregivers for PM shift, there is one (1) caregiver on call.

Administrative: Annual fee is current. All required signs are posted. LPA collected LIC500, LIC9020, and Certificate of Liability Insurance renewed on 8/23/2025. The Administrator Certificate expires on 2/6/2026.

LPA Interviewed three (3) caregivers and one (1) out of three (3) residents who was able to communicate.

No citation issued during this visit.

Exit interview conducted. Copy of this report signed and delivered to the Administrator.

NAME OF LICENSING PROGRAM MANAGER: Nichelle Gillyard
NAME OF LICENSING PROGRAM ANALYST: Perchui Khurshudyan
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2025
LIC809 (FAS) - (06/04)
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