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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607355
Report Date: 04/07/2026
Date Signed: 04/07/2026 01:01:33 PM

Document Has Been Signed on 04/07/2026 01:01 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: 5DATE:
04/07/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:55 AM
MET WITH:Sean Abalajon, AdministratorTIME VISIT/
INSPECTION COMPLETED:
01:15 PM
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On 04/07/26, at 8:55am, Licensing Program Analyst (LPA) Gina Saucedo arrived at the facility to conduct an unannounced, annual visit. Bernadette Babelonia, Caregiver was advised of the visit. Sean Abalajon, Administrator was called and arrived about five (05) minutes later.

LPA asked for the census, resident, and staff files.

The facility is a one (1) story home that has a total of five (05) bedrooms and three (03) bathrooms. Fire Clearance is approved for six (06) non-ambulatory and the facility has a hospice waiver for one (01) resident.

Last fire drill/Fire Alarms were conducted on 04/01/2026. The living and dining room are neat and clean. The smoke and carbon monoxide detectors are hardwired, interconnected and observed to be operational. Fire extinguisher is located near the kitchen, observed to be full and last purchased on 03/2026. There are cameras in the common areas. There is a signal system in the house.

Kitchen is sufficiently stocked with at least seven (07) days perishable and seven (07) days non-perishable food. Frozen foods are wrapped and stored appropriately. Kitchen cabinets contain extra food. Knives and sharps are observed to be locked and inaccessible to residents in one (1) of the top cabinets. The medication is kept in the kitchen area locked and inaccessible to the residents in a top cabinet. The toxins/chemicals are kept under the sink. There are two (2) sinks in the kitchen.



LIC 809C-continued
NAME OF LICENSING PROGRAM MANAGER: Troy Agard
NAME OF LICENSING PROGRAM ANALYST: Gina Saucedo
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/07/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/07/2026
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.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: THREE SYCAMORES ON GOULD
FACILITY NUMBER: 197607355
VISIT DATE: 04/07/2026
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There is one (1) washer and dryer outside in the backyard in a secured area.

Living Room and Dining Room: LPA observed the living room and furniture to be clean and in good repair. LPA observed the dining area to be clean and in good repair. The dining room area has several chairs for residents and a fire place covered. The facility temperature is between 68 and 69 degrees Fahrenheit.

There is another fire extinguisher in the hallway fully charged with an expiration date of 03/2026. There is also another fire place that is covered.

Bedrooms: Facility has five (5) bedrooms. All bedrooms are single occupied. Two (2) bedrooms have a private bathroom and the other bathroom is in the hallway.

Bathrooms: There are three (3) bathrooms that have proper grab bars, non-skid mats. The bathrooms contained a trash can with tight-fitting lid. Hot water was tested and measured between 110.8 F and 110.9 F within regulations.

Outside/Backyard: There is a detached garage. The outside/backyard has furniture for residents to have proper seating and a television. There is a no bodies of water. There is also a shed in the backyard and an extra refrigerator.

Administrative: The administrative Certification is current and expires 05/15/2026. There is a yes sign, Ombudsman, Personal Rights and Emergency Disaster Plan, Rights of Resident Council, Emergency Numbers against the wall of the facility on your right-hand side of the entrance of the facility. There is proof of insurance.

Staff/Resident Files: LPA reviewed five (5) resident files and four (4) staff files.

An exit interview was conducted, no citation(s) were issued and a copy of this report was given to the administrator.

NAME OF LICENSING PROGRAM MANAGER: Troy Agard
NAME OF LICENSING PROGRAM ANALYST: Gina Saucedo
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/07/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2026
LIC809 (FAS) - (06/04)
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