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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608641
Report Date: 05/30/2025
Date Signed: 05/30/2025 03:54:13 PM

Document Has Been Signed on 05/30/2025 03:54 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:PINK CORAL RESIDENCE IIFACILITY NUMBER:
197608641
ADMINISTRATOR/
DIRECTOR:		REY MEDELFACILITY TYPE:
740
ADDRESS:40343 N. 15TH STREET WESTTELEPHONE:
6614805985
CITY:PALMDALESTATE: CAZIP CODE:
93551
CAPACITY: 6CENSUS: 5DATE:
05/30/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:33 AM
MET WITH:Rey MedelTIME VISIT/
INSPECTION COMPLETED:
01:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Melissa Spaeth conducted an unannounced annual visit and was greeted by two caregivers. The Administrator, Rey Medel arrived at 11:00 am. The facility is licensed as an adult residential facility for the elderly to serve three ambulatory residents, three non-ambulatory which includes one bedridden resident. Staff confirmed there are five residents living in the facility. LPA and the Administrator began the tour of the facility at 10:15 am until 10:50 am. LPA observed the following:

Living Room– LPA Spaeth observed the living room contained comfortable seating and a television.

Kitchen/Dining room - The dining room and kitchen are combined. LPA Spaeth observed a seven-day supply of non-perishable food and a two-day supply of perishable foods. The fire extinguisher is located in the kitchen. LPA observed the knives were locked in a kitchen drawer, and the cleaning solutions were locked in a cabinet underneath the sink. A dining room table and chairs are located in the dining room area available for residents' use.

Bathrooms – LPA Spaeth observed the bathrooms contained hand soap, grab bars, slip resistant mats, paper towels, and a trash can.

Water Temperature - The water temperature was tested at 10:45 106.1 degrees F.

Continued on 809-C

NAME OF LICENSING PROGRAM MANAGER: Troy Agard
NAME OF LICENSING PROGRAM ANALYST: Melissa Spaeth
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/30/2025
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 S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: PINK CORAL RESIDENCE II
FACILITY NUMBER: 197608641
VISIT DATE: 05/30/2025
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Bedrooms – LPA Spaeth observed there are five residents' bedrooms in the facility. The bedrooms contained bed, linens, night stand, chair, chest of drawers, and a night lamp.

Staff Room – LPA observed the staff room was locked.

Laundry Room/Garage – LPA Spaeth observed the laundry room was locked. LPA observed the washer and dryer were located in the room. The laundry detergent was locked in a room within the laundry room. LPA observed an additional staff room was located in the garage area. LPA observed a deep freeze and two additional refrigerators which contained food.

Hallway Closet – LPA Spaeth observed a hallway closet contained additional clean linens. LPA observed another locked closet which contained additional PPE and hygiene items.

Backyard – LPA Spaeth observed comfortable seating in a shaded area. A locked gate surrounds the pool. The side gate leading from the backyard to the front yard was not locked.

Smoke/Carbon Monoxide Detectors – The smoke/carbon monoxide detectors were tested at 10:55 am and are properly working.

LPA reviewed resident's records at 11:00 am until 11:45 am. LPA reviewed the staff records at 11:45 am until 12:20 pm.


Exit interview conducted and a copy of the signed report was given.
NAME OF LICENSING PROGRAM MANAGER: Troy Agard
NAME OF LICENSING PROGRAM ANALYST: Melissa Spaeth
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2025
LIC809 (FAS) - (06/04)
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