197607223-10-23-2025-31-AS-NSHN-DMQVM8-20251023163308

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197607223
Report Date: 10/23/2025
Date Signed: 10/23/2025 04:33:22 PM

Document Has Been Signed on 10/23/2025 04:33 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:	ARDENVILLE HOME CARE I		FACILITY NUMBER:	197607223
ADMINISTRATOR/ DIRECTOR:	VICENTE A. ROBLES		FACILITY TYPE:	740
ADDRESS:	7747 SHADYCOVE		TELEPHONE:	(818) 767-6054
CITY:	BURBANK	STATE: CA	ZIP CODE:	91504
CAPACITY: 6		CENSUS: 5	DATE:	10/23/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	10:30 AM
MET WITH:	Vicente Robles - Administrator		TIME VISIT/ INSPECTION COMPLETED:	04:30 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Nadia Shahbazian conducted an Annual Required visit and inspection of the facility. LPA met Vicente Robles - Administrator and explained the reason for the visit. At 11:15am, with the assistance of Administrator, LPA took a tour of the physical plant. Required postings were observed in the dining area. The smoke/carbon monoxide detectors are hardwired and interconnected. At 11:40am, smoke and carbon monoxide detectors were tested and observed to function properly. The chime doors on each exit door, were observe to function properly as well. The fire extinguisher is located in the kitchen with charge date of 04/02/2025. Facility conducts quarterly fire drills; the last fire drill was conducted on 10/15/2025. Common Areas: These included the living room and dining room across from the kitchen and a sitting area at the front entry. The common areas were properly furnished with sofas, tables and chairs, appropriate for the number of residents. LPA observed several supply cabinets in the hallway. Laundry machine is located in the hallway and the laundry detergents were kept in locked cabinets atop the machines. LPA observed a bolted sliding door in the hallway; the door is completely shut and is inoperable. Kitchen: The kitchen appliances and fixtures were functional. LPA found a sufficient supply of perishable (2 days) and non-perishable (7 days) foods at the facility. All food supplies in containers were marked with purchase dates, to ensure food and safety regulations. Knives were stored in a locked drawer in the kitchen. All kitchen surfaces and appliances were clean and sanitary. Continued on 809-C

NAME OF LICENSING PROGRAM MANAGER: Troy Agard
NAME OF LICENSING PROGRAM ANALYST: Nadia Shahbazian
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 10/23/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2025

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 S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: ARDENVILLE HOME CARE I	FACILITY NUMBER: 197607223
	VISIT DATE: 10/23/2025

NARRATIVE

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Bedrooms: There were six (6) bedrooms designated for residents' use. All the bedrooms were properly furnished with appropriate furniture, beddings and linens with sufficient lighting. Three (3) of the bedrooms have exit doors. LPA observed the exit door in bedroom #1 to be obstructed by a cabinet; citation will be provided. Currently bedroom # 6 is vacant.

Bathrooms: There are three (3) bathrooms, one (1) for staff use and two (2) designated for residents' use; bedroom #5 has it's own bathroom. Both resident bathrooms had required grab bars and non-skid mats. Hot water temperature was measured at 110.5 and 111.7 degrees Fahrenheit.

Surrounding Grounds: There are two exits, one in the living room and one in the hallway, which are used as emergency exits, leading to the backyard. There was furniture appropriate for outdoor use, underneath a covered patio. The outdoor area was free of hazards and landscaping is maintained beautifully. There is no body of water in the premises. There is a detached garage, where additional emergency food, water and supplies are kept. Facility has an electrical generator, cable and internet access.

Resident Files: LPA conducted a file review of all resident records to insure compliance of licensing forms.

Staff Files: LPA also conducted a file review of staff records to insure forms and training are up to date and in compliance with licensing forms.

Medications: A locked cabinet near the kitchen is used to store medications. Medications for three out of five residents were counted and Medication Records were reviewed for proper documentation and administration. Facility has two complete first aid kits and a first aid manual.

Required Documents: Administrator license expiration date is 12/21/2025. Liability insurance for the facility has an expiration date of 07/02/2026.

Pursuant to Title 22 Division 6 of the CA Code of Regulations, deficiencies were cited (refer to LIC 809-D) during today's visit.

Exit Interview Conducted / Appeal Rights Discussed / A Copy of the Report Issued.

NAME OF LICENSING PROGRAM MANAGER: Troy Agard
NAME OF LICENSING PROGRAM ANALYST: Nadia Shahbazian
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 10/23/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 10/23/2025 04:33 PM - It Cannot Be Edited

Created By: Nadia Shahbazian On 10/23/2025 at 03:56 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., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: ARDENVILLE HOME CARE I	FACILITY NUMBER: 197607223
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/23/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87307(d)(6)

87307 Personal Accommodations and Services (6) All outdoor and indoor passageways and stairways shall be kept free of obstruction. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation the licensee did not comply with the section cited above in ensuring that the exit door in bedroom #1 to be obstructed by a cabinet, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/31/2025
	Plan of Correction
1 2 3 4	Licensee will ensure the cabinet in front of the exit door is removed and the passage way is unobstructed. Licensee will send pictures of the unobstructed exit door to LPA, by the POC date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Troy Agard
NAME OF LICENSING PROGRAM MANAGER:

	Nadia Shahbazian
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/23/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2025

LIC809 (FAS) - (06/04)

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