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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608363
Report Date: 09/17/2025
Date Signed: 09/17/2025 09:03:35 PM

Document Has Been Signed on 09/17/2025 09:03 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:LAKE BALBOA BOARDING CAREFACILITY NUMBER:
197608363
ADMINISTRATOR/
DIRECTOR:		ANAIT ASATRIANFACILITY TYPE:
740
ADDRESS:15830 MARLIN PLACETELEPHONE:
(818) 793-9814
CITY:LAKE BALBOASTATE: CAZIP CODE:
91406
CAPACITY: 6CENSUS: 5DATE:
09/17/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:31 AM
MET WITH:Anait AsatrianTIME VISIT/
INSPECTION COMPLETED:
05:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Sandra Urena arrived at the facility unannounced to conduct a required annual inspection. The LPA was greeted by staff, and staff contacted the Administrator by phone. The LPA spoke on the phone with the Administrator Anait Asatrian and explained the reason for the visit, the Administrator stated it would take them about an hour to get to the facility. The Administrator arrived at the facility shortly thereafter.

The LPA and the Administrator arrived at the facility. The LPA toured the physical plant areas inside and outside to ensure there are no health and safety hazards, and facility is in compliance with Title 22 Regulations.

COMMON AREAS: At the time of the visit, living room and dining room furniture was observed to be in good condition. The facility maintained a comfortable temperature of 76 degrees. Smoke detectors were tested and operational at the time of the visit. The carbon monoxide was not part of the smoke detector, and the facility did not have a carbon monoxide detector. The fire extinguisher was last serviced on 01/15/2024. The LPA observed the required postings throughout the common space. The facility serves residents with dementia, the auditory alarms on the exit doors were not functional at the time of visit. At approximately 10:48 the LPA observed a medication basket sitting on the dining room table which belonged to one of the residents and a bag of medication from the pharmacy also with bottles of medications accessible to residents in care.


Continues on LIC 809C...page 2.
NAME OF LICENSING PROGRAM MANAGER: Kasandra Lopez
NAME OF LICENSING PROGRAM ANALYST: Sandra Urena
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/17/2025
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 9
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)
Page: 2 of 9
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: LAKE BALBOA BOARDING CARE
FACILITY NUMBER: 197608363
VISIT DATE: 09/17/2025
NARRATIVE
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Staff living area is located in the front of the home. A connecting door between the staff living area and the facility area was observed. The LPA observed it to be unlocked and accessible to residents in care

KITCHEN: Knives are stored inaccessible in a kitchen drawer. Kitchen appliances were in operable condition. Kitchen cleaning supplies were observed under the kitchen sink in locked and inaccessible to residents in care. The facility has a sufficient supply of perishable and non-perishable food. The hot water temperature measured at….degrees Fahrenheit.

BEDROOMS: Bedrooms were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. There are four designated residents’ rooms. Linen closet is located inside bedroom # 4. The closet was observed to be locked at the time of the visit.

BATHROOMS: Two (2) bathrooms were observed to be clean and sanitary and in operating condition. First bathroom is located in the hallway; the hallway’s bathroom paper toilet holder was observed to be broken with only one half of the prongs still attached to the wall. Furthermore, the LPA observed cleaning supplies and grooming supplies next to the bathtub and accessible to residents in care, and requires a trash can with tight fitting lid. The second bathroom is a private bathroom which is located inside bedroom #4. The private bathroom needs to have safety grab bars installed. The bathrooms were sufficiently stocked with soap and paper towels. The hot water temperature measured in the hallway restroom at 119.9 degrees Fahrenheit.

LAUNDRY ROOM: A laundry area was observed with unlocked folding doors. A bottle of detergent was observed in an unlocked top cabinet above the washer and dryer and accessible to residents in care.

OUTDOOR AREA: The backyard has a covered outdoor area equipped with furniture for client use. There is a side gate for client use and is single-latched. No bodies of water noted. A back side gate behind the storage area was observed to be unlocked and the area accessible to residents in care. The Administrator attempted to close the gate, however the gate’s padlock was not working and did not engage. Gate needs to be fixed to close completely and engage lock.

Continues on LIC 809C... page 3.

NAME OF LICENSING PROGRAM MANAGER: Kasandra Lopez
NAME OF LICENSING PROGRAM ANALYST: Sandra Urena
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2025
LIC809 (FAS) - (06/04)
Page: 3 of 9
Document Has Been Signed on 09/17/2025 09:03 PM - It Cannot Be Edited


Created By: Sandra Urena On 09/17/2025 at 03:33 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: LAKE BALBOA BOARDING CARE
FACILITY NUMBER: 197608363

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/17/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1569.311
Regulations
Every residential care facility for the elderly shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 of Division 12. The department shall account for the presence of these detectors during inspections.

This requirement is not met as evidenced by:
Deficient Practice Statement
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3
4
Based on [(observation) the licensee did not comply with the section cited above in one carbon monoxide detector was missing, and the fire extingisher was expired, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/18/2025
Plan of Correction
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Administrator will purchase and install a detector/ and fire extinguisher..
Type A
Section Cited
CCR
87309(a)
Storage Space and Access
(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) the licensee did not comply with the section cited above in three cleaning solutions were observed which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/19/2025
Plan of Correction
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Administrator will ensure all cleaning solutions will be locked by providing functioning locks and cabinets.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Kasandra Lopez
NAME OF LICENSING PROGRAM MANAGER:
Sandra Urena
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/17/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/17/2025


LIC809 (FAS) - (06/04)
Page: 4 of 9
Document Has Been Signed on 09/17/2025 09:03 PM - It Cannot Be Edited


Created By: Sandra Urena On 09/17/2025 at 03:34 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: LAKE BALBOA BOARDING CARE
FACILITY NUMBER: 197608363

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/17/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87412(a)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on (record review)], the licensee did not comply with the section cited above in one out of three staff files was not complete and maintained, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/22/2025
Plan of Correction
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Administrator will email the LPA proof of fingerprint clearance, and association to the facility.
Type A
Section Cited
CCR
87465(h)(2)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation), the licensee did not comply with the section cited above in several medication bottles (11) were observed on dining room table,] which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/17/2025
Plan of Correction
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Administrator locked medication at the time of the visit.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Kasandra Lopez
NAME OF LICENSING PROGRAM MANAGER:
Sandra Urena
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/17/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/17/2025


LIC809 (FAS) - (06/04)
Page: 5 of 9
Document Has Been Signed on 09/17/2025 09:03 PM - It Cannot Be Edited


Created By: Sandra Urena On 09/17/2025 at 03:35 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: LAKE BALBOA BOARDING CARE
FACILITY NUMBER: 197608363

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/17/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(c)(2)
Incidental Medical and Dental Care Services
(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (2) Once ordered by the physician the medication is given according to the physician's directions.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on medication audit, the licensee did not comply with the section cited above in three medications out of three audited were not given according to physicians directions, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/26/2025
Plan of Correction
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Administrator will contract a qualified professional to provide medication administration training and will email the training records/ certification for the qualified professional and staff attending training to LPA
Type A
Section Cited
CCR
87506(a)
Resident Records
(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff.

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 in one out of five residents records was not available for review, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/18/2025
Plan of Correction
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Administrator will emaill full residents missing file to LPA by end of closing business day.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Kasandra Lopez
NAME OF LICENSING PROGRAM MANAGER:
Sandra Urena
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/17/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/17/2025


LIC809 (FAS) - (06/04)
Page: 6 of 9
Document Has Been Signed on 09/17/2025 09:03 PM - It Cannot Be Edited


Created By: Sandra Urena On 09/17/2025 at 03:35 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: LAKE BALBOA BOARDING CARE
FACILITY NUMBER: 197608363

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/17/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(f)(1)
Incidental Medical and Dental Care Services
(f) Emergency care requirements shall include the following: (1) The name, address, and telephone number of each resident's physician and dentist shall be readily available to that resident, the licensee, and facility staff.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on (record review)], the licensee did not comply with the section cited above in one LIC 9020 was not avaiable for review, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/18/2025
Plan of Correction
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Administrator will email LPA completed LIC 9020 by end of day.
Type B
Section Cited
CCR
87303(e)(4)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (4) Grab bars shall be maintained for each toilet, bathtub and shower used by residents.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply one toilet grab bars and toilet grab bar and one paper toilet holder were not available during the visit, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/26/2025
Plan of Correction
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Administrator will email picture of repairs to LPA.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Kasandra Lopez
NAME OF LICENSING PROGRAM MANAGER:
Sandra Urena
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/17/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/17/2025


LIC809 (FAS) - (06/04)
Page: 7 of 9
Document Has Been Signed on 09/17/2025 09:03 PM - It Cannot Be Edited


Created By: Sandra Urena On 09/17/2025 at 03:36 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: LAKE BALBOA BOARDING CARE
FACILITY NUMBER: 197608363

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/17/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on (record review)], the licensee did not comply with the section cited above the administrator didnot have record of fire drills, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/19/2025
Plan of Correction
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Administrator will conducte frire drill and will email LPA record of the drill taken place.
Type B
Section Cited
HSC
1569.695(e)(4)
Other Provisions
(e) A facility shall have all of the following information readily available to facility staff during an emergency: (4) Contact information for the responsible party and physician for each resident.

This requirement is not met as evidenced by:
Deficient Practice Statement
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3
4
Based on (record review)], the licensee did not comply with the section cited above as LIC 9020 was not completed nor a list was readilly available upon request, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/19/2025
Plan of Correction
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2
3
4
Administartor will email completed LIC 9020 and LIC 500 forms to LPA.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Kasandra Lopez
NAME OF LICENSING PROGRAM MANAGER:
Sandra Urena
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/17/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/17/2025


LIC809 (FAS) - (06/04)
Page: 8 of 9
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: LAKE BALBOA BOARDING CARE
FACILITY NUMBER: 197608363
VISIT DATE: 09/17/2025
NARRATIVE
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Pg 3.
RECORDS: Records review began at 12:25 p.m. Residents’ records were reviewed for, but not limited to care plans, medical records, admissions agreement, and consent forms. Record review revealed that four out of four files were missing some or all of the following: SNP(signatures). No LIC 601/ID, No LIC621- SPV- MA missing Physician contact information. One out of five residents’ file was missing. Per the Administrator the resident was admitted to facility without any personal or medical documentation. At the time of the visit the LPA attempted to communicate with the resident’s family contact, the call was unanswered, and LPA was unable to leave message. Resident’s DOB and last name is unknown. Personnel records were reviewed for, but not limited to health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. One (1) out of three (3) staff files was missing, some or all of the following required forms: LIC 501, 508, 9052, ED, FPCL- Staff works two days per week.

MEDICATIONS: Medications review began at 02:05 p.m.; medications are centrally stored and locked in a cabinet in the common area; medications are labeled and were checked for expiration dates. Medications were not properly documented on the centrally stored medications and destruction record form (LIC622). Errors observed during the medication review, as one out of one medication audit indicated that the following medications were not administered as prescribed, where medications were not given daily: Methocarbamol (500 mg/30 count), Benazepril (40mg/30 count), Amlodipine.

The LPA requested the following documents:


- LIC500 Personnel Report-Was not available for review.
- LIC9020 Client Roster-Available- but not completely filled-out.
- Liability of Insurance.

The following deficiencies were observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code.

The Administrator was informed of the late license fees due for the facility.

Exit interview conducted. A copy of the report and Appeal Rights was issued.

NAME OF LICENSING PROGRAM MANAGER: Kasandra Lopez
NAME OF LICENSING PROGRAM ANALYST: Sandra Urena
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2025
LIC809 (FAS) - (06/04)
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