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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608523
Report Date: 11/04/2025
Date Signed: 11/04/2025 01:48:13 PM

Document Has Been Signed on 11/04/2025 01:48 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:CALIFORNIA SENIOR OF SHERMAN OAKSFACILITY NUMBER:
197608523
ADMINISTRATOR/
DIRECTOR:		JEFFERSON REYESFACILITY TYPE:
740
ADDRESS:14802 MORRISON STREETTELEPHONE:
(818) 849-5525
CITY:SHERMAN OAKSSTATE: CAZIP CODE:
91403
CAPACITY: 6CENSUS: 4DATE:
11/04/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:40 AM
MET WITH:Jefferson Reyes - LicenseeTIME VISIT/
INSPECTION COMPLETED:
02:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Quoc Huynh arrived at the facility unannounced to conduct a required annual visit at 10:40AM. The LPA met with the Licensee Jefferson Reyes and explained the reason for the visit. Entrance interview conducted.

Beginning at 10:44AM, the LPA and Licensee 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. The following was observed:

COMMON AREAS: At the time of the visit, living room and dining room furniture was observed to be in good condition. Nightlights were observed throughout the facility. The facility maintained a comfortable temperature throughout the visit. The LPA observed required postings along the entryway walls.

KITCHEN: Knives were stored inaccessible in a drawer in addition to secured cleaning supplies under the kitchen sink. Kitchen appliances were in good and operable condition. The facility had a sufficient supply of perishable, non-perishable, and emergency food. Food in the refrigerator and freezer were of good quality. Resident files and medications were locked and inaccessible.

Report Continued on LIC 809-C
NAME OF LICENSING PROGRAM MANAGER: Kristin Heffernan
NAME OF LICENSING PROGRAM ANALYST: Quoc Huynh
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 11/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/04/2025
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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Document Has Been Signed on 11/04/2025 01:48 PM - It Cannot Be Edited


Created By: Quoc Huynh On 11/04/2025 at 01:17 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: CALIFORNIA SENIOR OF SHERMAN OAKS
FACILITY NUMBER: 197608523

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/04/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87202(a)
Fire Clearance
(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal:

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 1 fire door did not trigger and self-close when tested which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/05/2025
Plan of Correction
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The Licensee will contact an electrician and handyman to repair the fire door and send CCL proof by POC due date.
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:
Quoc Huynh
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 11/04/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/04/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/04/2025 01:48 PM - It Cannot Be Edited


Created By: Quoc Huynh On 11/04/2025 at 01:17 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: CALIFORNIA SENIOR OF SHERMAN OAKS
FACILITY NUMBER: 197608523

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/04/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.618(c)(4)
Other Provisions
(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (4) Ensure that the facility is clean, safe, sanitary, and in good repair at all times.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above in 1 live-in staff room containing personal items was acessible to residents which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/07/2025
Plan of Correction
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The Licensee will install a lock on the staff door and send proof by POC due date.
Type B
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above in staff did not receive 8 hours of dementia training and 8 hours of medication training which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/11/2025
Plan of Correction
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The Licensee will submit a statement of understanding outlining a revised training schedule/plan that includes the required training hours and topics and provide it to CCL by POC due date.
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:
Quoc Huynh
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 11/04/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/04/2025


LIC809 (FAS) - (06/04)
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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: CALIFORNIA SENIOR OF SHERMAN OAKS
FACILITY NUMBER: 197608523
VISIT DATE: 11/04/2025
NARRATIVE
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BEDROOMS/RESTROOMS: There were six (6) total bedrooms: five (5) resident bedrooms and one (1) staff bedroom. Bedroom #4 had a direct exit to the outside and was approved for one (1) Bedridden resident. Bedrooms were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. Extra linens were observed in the hallway. The LPA explained to the Licensee that the live-in staff room must remain locked and inaccessible to residents at all times. The Licensee understood and stated they will purchase a lock for the door. There were three (3) total restrooms: one (1) private resident restroom, one (1) shared resident restroom, and one (1) staff restroom. Restrooms were clean and sanitary and in operating condition with grab bars and non-slip surfaces. All restrooms were sufficiently stocked with soap and paper products. Hot water was tested and measured between 112.6 degrees F and 113 degrees F, which was in the required range.

OUTDOOR AREA: The rear of the house had a laundry room with operational machines in good condition. Cabinets in the laundry room contained general storage, emergency water, and laundry detergent. The backyard had a covered patio area equipped with furniture for residents’ use. There was one (1) side gate for emergency exit use and was self-latching. All exits and passageways were free of obstruction. The rear yard also had a detached garage and a shed that contained general storage and was inaccessible to residents. Additionally, the garage had an attached driveway with a manual gate.

RECORDS: Record review began at 11:09AM. Resident records were reviewed for, but not limited to care plans, physician's report, admissions agreement, and consent forms. The LPA observed four (4) out of four (4) resident Appraisals/Needs and Services Plans were not signed by the residents or their conservators. The Licensee stated they would flag the documents and obtain signatures. The LPA also explained the importance of updating resident Appraisals and Physician’s Reports annually per regulation. Personnel records were reviewed for, but not limited to health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. The LPA reviewed training requirements with the Licensee as annual staff training did not include eight (8) hours of dementia training and eight (8) hours of medication training.

Continued on LIC 809-C
NAME OF LICENSING PROGRAM MANAGER: Kristin Heffernan
NAME OF LICENSING PROGRAM ANALYST: Quoc Huynh
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 11/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2025
LIC809 (FAS) - (06/04)
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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: CALIFORNIA SENIOR OF SHERMAN OAKS
FACILITY NUMBER: 197608523
VISIT DATE: 11/04/2025
NARRATIVE
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INFECTION CONTROL/EMERGENCY DISASTER PLAN: During today's visit, the LPA reviewed the facility's infection control plan and emergency disaster plan. Both documents were observed to be complete and updated annually as required. Emergency disaster drills are conducted quarterly, with the last documented drill on 10/02/2025. Smoke and carbon monoxide detectors were tested at 12:06PM and were operational at the time of the visit. The facility’s magnetic fire door did not trigger and self-close during this time. The Licensee stated they will have the electrical wiring of the fire door checked. Fire extinguishers were fully charged and purchased on 9/26/2025.

MEDICATIONS: Medication review began at 12:14PM. Medications were centrally stored and kept inaccessible. Medications were observed for two (2) residents. Medications were labeled and checked for expiration dates. Medications were properly documented on the centrally stored medications and destruction record. No errors observed during the medication review.

An immediate civil penalty of $500 for a violation of the facility’s fire clearance was issued (Refer to LIC 412M). The Licensee understands that continued violation of the facility’s fire clearance may result in additional civil penalties.

Pursuant to Title 22 CA Code of Regulations and/or the Health and Safety Code, the following deficiencies were cited (Refer to LIC 809-D).

Exit interview conducted. A copy of the appeal rights and today's report was reviewed and provided.
NAME OF LICENSING PROGRAM MANAGER: Kristin Heffernan
NAME OF LICENSING PROGRAM ANALYST: Quoc Huynh
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 11/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2025
LIC809 (FAS) - (06/04)
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