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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607355
Report Date: 02/19/2025
Date Signed: 02/19/2025 06:15:13 PM

Document Has Been Signed on 02/19/2025 06:15 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 - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
05:40 PM
MET WITH:Assistant Administrator, Sean Draeco AbalajonTIME VISIT/
INSPECTION COMPLETED:
06:25 PM
NARRATIVE
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In conjunction with a One (1) year inspection to the facility, Licensing Program Analyst (LPA) Antonia Alvizar-Ettima conducted a case management visit to address the deficiencies unrelated to the inspection.

During inspection, at about 1:52p.m., LPA noted resident #1 (R1) was restrained to the wheelchair with a gait belt as postural support. The gait belt easy release buckle was on the back of the wheelchair. At about 1:53p.m. LPA interviewed staff #1-#2 (S1-S2) and indicated that the gait belt is used to prevent R1 from standing and sliding off wheelchair. Interview with R1 revealed that did not know why they placed the gait belt on them. R1 illustrated that was not able to release the gait belt on their own during emergency. LPA interviewed Administrator and requested prescription for the postural supports. Administrator was unable to provide the document.

Based on inspection, observation and interviews it was concluded that licensee did not ensure that postural support provided to resident not depriving residents’ movement. Resident was restrained to the wheelchair and had no ability to release it.


Deficiencies will be cited and recorded on LIC809D.

Exit interview conducted. Copy of report, and appeal rights issued.
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 06:15 PM - It Cannot Be Edited


Created By: Antonia Alvizar-Ettima On 02/19/2025 at 06:06 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
87608(a)(5)

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87608 Postural Supports (a) ...The facility shall provide... care for the resident in those activities... unable to do for themself. Postural supports may be used ...conditions. (5) Under no circumstances shall postural supports...limiting the use of a resident's hands or feet.
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The licensee will provide in-service for postural support to ensure the safety of residents in care and will ensure care staff is schedule to assist R1. Licensee will submit in-service and staff schedule to LPA by due date.
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This requirement is not met as evidenced by. The licensee did not ensure that postural support provided to R1 is not depriving R1s’ movement. R1 was restrained to the wheelchair and had no ability to release it. This possess an immediate health and safety hazard to residents in care.
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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)
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