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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608491
Report Date: 10/16/2025
Date Signed: 10/16/2025 03:04:37 PM

Document Has Been Signed on 10/16/2025 03:04 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.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:ACE SENIOR CAREFACILITY NUMBER:
197608491
ADMINISTRATOR/
DIRECTOR:		ELAINE BOTEFACILITY TYPE:
740
ADDRESS:22910 SHERMAN WAYTELEPHONE:
(818) 914-5002
CITY:WEST HILLSSTATE: CAZIP CODE:
91307
CAPACITY: 6CENSUS: 6DATE:
10/16/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:20 PM
MET WITH:Rosa RemorinTIME VISIT/
INSPECTION COMPLETED:
03:20 PM
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At approximately 12:20 p.m. on 10/16/25, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced annual inspection. LPA met with Staff #1 (S1) and disclosed the reason for the visit. LPA and S1 toured the facility inside and out.

The facility was last visited on 08/22/24 for an annual visit. It is a single story building with seven (07) bedrooms, four (04) bathrooms, kitchen, garage, common areas, and outdoor areas. It has an approved fire clearance for six (06) nonambulatory residents, of which six (06) may be bedridden. The facility serves residents with dementia. Approved hospice waivers for four (04). Surveillance cameras are used in common and exterior areas.

The front entrance is gated and unlocked. Shaded seating areas were observed at the front and rear of the facility. At the main entrance, LPA observed postings for the house rules, facility sketch, administrator certificate, facility license, emergency disaster plan, COVID precautions, personal rights, theft and loss policy, rights of resident councils, confidential complaint contacts, ombudsman contacts, and oxygen-in-use signs. A screening station at the front contained a visitor log and sanitizer.

Walls, floors, windows, screens, and blinds were clean and in good repair. At 12:30 p.m. LPA measured the room temperature to be 77 degrees Fahrenheit. The living room contained a television, reading materials, exercise equipment, and furniture in good repair. At 12:40 p.m. the house telephone was called and deemed operational.

NAME OF LICENSING PROGRAM MANAGER: Naira Margaryan
NAME OF LICENSING PROGRAM ANALYST: Nicholas Reed
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 10/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/16/2025
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 3
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.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: ACE SENIOR CARE
FACILITY NUMBER: 197608491
VISIT DATE: 10/16/2025
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The facility has seven (07) bedrooms. One (01) bedroom is designated as a staff room. The staff room was free of hazards. All bedrooms contained a chair, lamp, nightstand, storage, and a bed with adequate bedding. All furnishings were clean and in good condition. Exit doors from rooms were unlocked. Six (06) out of six (06) auditory alarms in resident bedrooms were tested and functioning. Ramps leading out were secure, and emergency exit paths were free of debris or hazards.

The back yard contained a gardened area and an unlocked exit gate. The storage shed was locked and contained tools and chemical cleaners. Interview with S1 at approximately 1:00 p.m. revealed the large tree had recently been removed form the back yard.

A secondary living room contained a piano and a treadmill. LPA observed an adequate supply of perishable and non-perishable foods in the kitchen refrigerator and freezer. Appliances were in good condition. Sharps were locked below the counter top. Cleaning solutions were locked below the sink. Medications and confidential files were locked in separate cabinets. The garage was unlocked and contained a washing machine, a dryer, and extra supplies. Both appliances were in working order. Detergents were locked above them in a cabinet.

The facility has four (04) bathrooms. One (01) bathroom is private, and three (03) are shared. All bathrooms contained liquid soap, trash cans with tight fitting lids, grab bars near the toilet and shower or commodes, and a non-skid mat in the shower. At approximately 1:10 p.m. LPA measured the water temperature to be 105.1 degrees Fahrenheit in one of the shared bathrooms.

At approximately 1:20 p.m., smoke and carbon monoxide detectors were tested and operational. At approximately 1:25 p.m. LPA observed a fully charged fire extinguisher in the kitchen. It was purchased in 2025 as indicated by the date on the bottom, though it did not have a receipt attached.

At 1:30 p.m. LPA conducted a records review of resident and personnel files. All files were complete and available for audit.

During today’s inspection, no immediate health or safety concerns were observed.

Exit interview conducted. Copy of report provided.

NAME OF LICENSING PROGRAM MANAGER: Naira Margaryan
NAME OF LICENSING PROGRAM ANALYST: Nicholas Reed
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/16/2025
LIC809 (FAS) - (06/04)
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