<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607355
Report Date: 02/19/2025
Date Signed: 02/19/2025 05:37:28 PM

Document Has Been Signed on 02/19/2025 05:37 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:THREE SYCAMORES ON GOULDFACILITY NUMBER:
197607355
ADMINISTRATOR/
DIRECTOR:		MARK YULEFACILITY TYPE:
740
ADDRESS:4701 GOULD AVENUETELEPHONE:
(818) 952-0491
CITY:LA CANADASTATE: CAZIP CODE:
91011
CAPACITY: 6CENSUS: 3DATE:
02/19/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:40 AM
MET WITH:Assistant Administrator, Sean Draeco Abalajon and Administrator, Mark YuleTIME VISIT/
INSPECTION COMPLETED:
04:49 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) Antonia Alvizar-Ettima met with the Administrator and Assistant Administrator and an unannounced Required One (1) year inspection visit to this facility.

During inspection, LPA Alvizar-Ettima discovered the following Part-Time Staff (S1) and (S2) have been present without a Background Clearance or Transfer and Association to this facility. S1 job title is Caregiver, first day of work was 07/11/2022. S2 job title is Caregiver, first day of work was 10/18/2023.


LPA request/received S1 Republika NG Pilipinas. LPA request/received S2 United States of America Permanent Resident Card. LPA verified using Guardian Background System Check, staff S1 and S2 names did not appeared on facility roster.

S1- Bernadette O. Babelonia DOB: 01/12/1968
S2 - Marissa Gamboa DOB: 08/04/1969


A citation and civil penalty were issued. Copy of this report was provide to Assistant Administrator, Sean Abalajon.
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Antonia Alvizar-Ettima
LICENSING EVALUATOR SIGNATURE: DATE: 02/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/19/2025
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 2
Document Has Been Signed on 02/19/2025 05:37 PM - It Cannot Be Edited


Created By: Antonia Alvizar-Ettima On 02/19/2025 at 05:07 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: THREE SYCAMORES ON GOULD
FACILITY NUMBER: 197607355

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/19/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/20/2025
Section Cited
CCR
87355(b)(2)

1
2
3
4
5
6
7
All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working... in a licensed facility: (2)Request a transfer of a criminal record clearance as specified in Section 87355(c)... This requirement is not met as evidence by:
1
2
3
4
5
6
7
Administrator will completed Criminal Background Clearance or Transfer & Associated S1 & S2 to facility. Administrator will provide documentation to LPA. S1 & S2 exit the facility and will not return until Background Clearance and Associated.
8
9
10
11
12
13
14
Based on interview and review of Guardian Background System staff S1&S2 are not Criminal Background Clearanced or Transfer & Associated to this facility. No documentation has been submitted to CCLD. This poses a potential risk to residents in care.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Naira Margaryan
LICENSING EVALUATOR NAME:Antonia Alvizar-Ettima
LICENSING EVALUATOR SIGNATURE:
DATE: 02/19/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/19/2025


LIC809 (FAS) - (06/04)
Page: 2 of 2