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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607495
Report Date: 08/12/2025
Date Signed: 08/12/2025 02:06:14 PM

Document Has Been Signed on 08/12/2025 02:06 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 N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:CHATEAU LE PETITE IIIFACILITY NUMBER:
197607495
ADMINISTRATOR/
DIRECTOR:		BELINDA DOLINSKYFACILITY TYPE:
740
ADDRESS:24312 CARIS STREETTELEPHONE:
(818) 610-1082
CITY:WOODLAND HILLSSTATE: CAZIP CODE:
91367
CAPACITY: 6CENSUS: 6DATE:
08/12/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:24 AM
MET WITH:Dexter OlavarioTIME VISIT/
INSPECTION COMPLETED:
02:15 PM
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Licensing Program Analyst (LPA) Angela Barutyan arrived at the facility unannounced to conduct a required annual visit at 11:24AM. LPA met with Head Caregiver (HC) Dexter Olavario. Administrator Belinda Dolinsky could not be on site at the time of the visit, but Dexter Olavario was designated to sign in their place. Entrance interview conducted.

Beginning at 11:26AM, the LPA, along with the HC toured the physical plant areas inside and outside to ensure there are no health and safety hazards and that facility is in compliance with Title 22 Regulations. The following was observed:

Fire extinguishers were fully charged and last serviced 07/24/2025. Hardwired smoke detectors and carbon monoxide detector in kitchen were tested at 11:45AM and all were functional at the time of the visit. LPA observed exit alarms by all doors which were functional and operating.

KITCHEN/GARAGE: LPA inspected the kitchen at 11:26AM. Knives and sharps were stored in a locked drawer. Kitchen appliances were in operable condition. The facility had a sufficient supply of perishable and non-perishable food. LPA observed emergency food and water supply in the pantry next to the kitchen. Food was stored at appropriate temperatures. The locked garage is accessed through the kitchen. LPA observed an additional refrigerator/freezer and cleaning supplies in the garage.

BEDROOMS: The facility consists of eight (8) total bedrooms, of which six (6) are designated for single-resident use and two (2) are designated for staff use. All resident rooms have exits to the exterior. All resident rooms were observed to be furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. Report Continued on LIC 809-C

NAME OF LICENSING PROGRAM MANAGER: Kristin Heffernan
NAME OF LICENSING PROGRAM ANALYST: Angela Barutyan
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 08/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/12/2025
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 N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: CHATEAU LE PETITE III
FACILITY NUMBER: 197607495
VISIT DATE: 08/12/2025
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BATHROOMS: There are six (6) total bathrooms, of which five (5) are attached to resident rooms and 1 (one) is for common use. LPA observed bathrooms to be clean, sanitary and in operating condition with grab bars and slip-resistant surfaces. Hot water temperatures were measured in three (3) bathrooms and were between 105.6 F-119.8 degrees F, which is within the required range.

COMMON AREAS/LAUNDRY: This includes the living room, exercise room, and dining room. LPA observed common areas to be clean and properly furnished at the time of the visit. LPA observed a fireplace in the living room that was adequately screened. Facility was maintained at a comfortable temperature. LPA observed surveillance cameras in the common areas. LPA observed storage space closets in hallway containing clean linens for resident use. LPA observed the laundry room adjacent to the staff room. Laundry room had a washer and dryer and locked cleaning supplies.

OUTDOOR SPACE: The backyard had a covered patio area with furniture including a table and chairs. There were no bodies of water on the premises. One (1) side pathway is used as an emergency exit which was free of obstruction and had a self-closing and self-latching gate.

RECORD REVIEW: LPA began record review at 11:52AM. LPA reviewed six (6) out of six (6) resident files and four (4) staff files for documents including, but not limited to: health screening, TB test, staff training records, fingerprint clearance, resident physician's report, needs and service appraisal, and personal rights. LPA observed half rails in five (5) resident rooms and full rails in one (1) resident room. Five (5) resident files were missing the half bed rail orders, and one (1) resident file was missing full rail orders and the resident was not receiving hospice services. Staff files were complete and had no missing documents.

MEDICATION REVIEW: Medications are centrally stored and locked in a cabinet in the kitchen. LPA began medication review at 01:05PM and medications for two (2) residents were observed. All medications were labeled and maintained in compliance with label instructions, and state and federal law.

INFECTION CONTROL/EMERGENCY DISASTER PLANNING: LPA reviewed the facility's infection control practices and the facility's emergency disaster plan. The facility’s policies and procedures as it pertains to infection control are adequate. Emergency disaster drill was conducted during the visit.

Pursuant to Title 22, CA Code of Regulations, the following deficiency was cited (refer to LIC 809-D). Administrator was informed that failure to correct deficiency may result in civil penalties.

Exit interview conducted, report issued, and appeal rights provided.

NAME OF LICENSING PROGRAM MANAGER: Kristin Heffernan
NAME OF LICENSING PROGRAM ANALYST: Angela Barutyan
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/12/2025 02:06 PM - It Cannot Be Edited


Created By: Angela Barutyan On 08/12/2025 at 01:43 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. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: CHATEAU LE PETITE III
FACILITY NUMBER: 197607495

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/12/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87608(a)(3)
Postural Supports
(a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions: (3) A written order from a physician indicating the need for the postural support shall be maintained in the resident's record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above as six (6) out of six (6) resident files were missing written orders for bed rails which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/26/2025
Plan of Correction
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Facility designee stated that half bed rail orders will be obtained or removed if not needed and the full bed rail will be changed to a half rail. Written orders will be submitted to CCLD by 08/26/2025.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
Kristin Heffernan
NAME OF LICENSING PROGRAM MANAGER:
Angela Barutyan
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/12/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/12/2025


LIC809 (FAS) - (06/04)
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