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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608694
Report Date: 11/06/2025
Date Signed: 11/06/2025 02:18:17 PM

Document Has Been Signed on 11/06/2025 02:18 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:VILLAGE AT SHERMAN OAKS, THEFACILITY NUMBER:
197608694
ADMINISTRATOR/
DIRECTOR:		GRACE HARTNETTFACILITY TYPE:
740
ADDRESS:5450 VESPER AVETELEPHONE:
(818) 994-7900
CITY:SHERMAN OAKSSTATE: CAZIP CODE:
91411
CAPACITY: 179CENSUS: 158DATE:
11/06/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:49 AM
MET WITH:Grace HartnettTIME VISIT/
INSPECTION COMPLETED:
02:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Trevor Byrne arrived to the facility at 09:49 AM to conduct an unannounced Case Management - Deficiencies visit at the facility today. LPA met with facility Executive Director (ED) Grace Hartnett entrance interview conducted and the reason for the visit was explained.

The purpose of today’s visit was to follow-up on two (2) self-reported incidents that occurred on 10/04/2025 and 10/12/2025. During today’s visit, the LPA conducted interviews with the Executive Director (ED) and the Director of Assisted Living (DOAL), conducted a file review for one (1) resident, and conducted a medication review for one (1) resident between approximately 09:52 AM and 01:50 PM.

On 11/04/2025 at 6:37 PM and on 11/05/2025 at 1:32 PM Community Care Licensing Division (CCLD) received two (2) self-reported incident reports pertaining to Resident #1 (R1). The two incidents occurred at the facility on 10/04/2025 at 11:00 AM and on 10/12/2025 at 10:00 AM. LPA interviewed the ED and DOAL and asked why the reports were not submitted to CCLD in a timely manner. ED and DOAL explained that a combination of confusion between R1's hospice company not receiving a medication order and the DOAL being out sick from the facility during the times the incidents occurred both contributed to the incident reports being submitted outside of the required time frame. LPA informed ED and DOAL that a written report shall be submitted to the licensing agency and to the person responsible for the resident within seven (7) days of the occurrence any incident which threatens the welfare, safety or health of any resident. ED and DOAL confirmed that they are aware of the reporting requirement and agreed to submit all future reports to CCLD in a timely manner and ensure someone in leadership is available to review/approve reports for submission to CCLD in the event of an absence of the ED or DOAL.

Continued on LIC 809C.

NAME OF LICENSING PROGRAM MANAGER: Kasandra Lopez
NAME OF LICENSING PROGRAM ANALYST: Trevor Byrne
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 11/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/06/2025
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: VILLAGE AT SHERMAN OAKS, THE
FACILITY NUMBER: 197608694
VISIT DATE: 11/06/2025
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The 10/04/2025 self-reported incident report stated that R1 had missed administration of Medication #1 (M1) between 09/30/2025-10/03/2025. DOAL conducted a review of R1’s medications on 10/04/2025 and observed that M1 had not been given as prescribed since 09/29/2025. DOAL stated that there was verbal communication between facility staff and R1's prescribing physician to hold the administration of M1 pending lab results. LPA determined that further investigation into the missed medication administration is needed prior to determining if a citation is warranted. LPA informed ED that CCLD may return at a later date if it is determined that the issuance of a citation or assessment of a civil penalty is deemed warranted for this incident. ED expressed understanding and agreed to submit any relevant documentation to LPA for review.

Pursuant to Title 22, California Code of Regulations, the following deficiency was cited (refer to LIC 809-D.) Exit interview conducted and copy of the report and appeal rights were issued.

NAME OF LICENSING PROGRAM MANAGER: Kasandra Lopez
NAME OF LICENSING PROGRAM ANALYST: Trevor Byrne
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 11/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/06/2025 02:18 PM - It Cannot Be Edited


Created By: Trevor Byrne On 11/06/2025 at 01:23 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: VILLAGE AT SHERMAN OAKS, THE
FACILITY NUMBER: 197608694

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/06/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/20/2025
Section Cited
CCR
87211(a)(1)(D)

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87211 Reporting Requirements
(a) Each licensee shall furnish...:
(1) A written report shall be submitted to... licensing...within seven days of...
(D) Any incident which threatens the welfare, safety or health of any resident...
This requirement is not met as evidenced by:
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ED and DOAL agreed to submit a written statement confirming that all future reports will be submitted to CCLD within the required timeframe and will ensure someone in leadership is available to review/approve reports for submission to CCLD in the event of an absence of the ED or DOAL.
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Based on record review and interview the licensee did not comply with the section cited above as two incident reports pertaining to incidents involving R1 were not submitted to licensing within the required timeframe which posed a potential health, safety, or personal rights risk to clients in care.
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ED and DOAL agreed to submit their plan on how they will ensure adequate coverage to review/submit reports along with the signed statement mentioned above to CCLD no later than POC due date.

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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.
Kasandra Lopez
NAME OF LICENSING PROGRAM MANAGER:
Trevor Byrne
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 11/06/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/06/2025


LIC809 (FAS) - (06/04)
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