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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608694
Report Date: 11/19/2025
Date Signed: 11/19/2025 01:06:01 PM

Document Has Been Signed on 11/19/2025 01:06 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: 156DATE:
11/19/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:14 AM
MET WITH:Yamilette CapillaTIME VISIT/
INSPECTION COMPLETED:
01:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Trevor Byrne arrived to the facility at 10:14 AM to conduct an unannounced Case Management - Deficiencies visit at the facility today. LPA met with facility Executive Director (ED) Grace Hartnett and the Director of Assisted Living (DOAL) Yamilette Capilla entrance interview conducted and the reason for the visit was explained.

The purpose of today’s visit was to follow-up on a self-reported incident that occurred on 10/04/2025. During today’s visit, the LPA conducted interviews with the Executive Director (ED) and the Director of Assisted Living (DOAL), reviewed Resident #1’s (R1) medication administration record (MAR), and collected copies of pertinent documentation between approximately 10:20 AM and 11:48 AM.

Continued on LIC 809C.

NAME OF LICENSING PROGRAM MANAGER: Kasandra Lopez
NAME OF LICENSING PROGRAM ANALYST: Trevor Byrne
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 11/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/19/2025
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: 11/19/2025
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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. On the 11/06/2025 visit to the facility the DOAL stated that there was verbal communication between facility staff and R1's prescribing physician to hold the administration of M1 pending lab results. During today’s visit the facility was unable to provide documentation of the physician’s orders to hold administration of M1. LPA observed R1’s MAR to contain entries of administered M1 between 10/05/2025 to 10/16/2025. LPA did not observe MAR entries for R1’s M1 administration between 09/30-10/03. LPA observed a physicians order to hold M1 administration dated 10/09/2025, LPA did not observe any further orders to resume M1 administration. DOAL informed LPA that the entries were not cleared at the time of the administration and were cleared at a later date by a different med tech. DOAL stated that because of this, notes were unable to be added noting that the medication was not administered on those dates. DOAL provided LPA with signed statements from the Med tech on duty and the med tech that cleared the entries stating that M1 was not given to R1 on 10/16, 10/15, 10/10, or 10/09. LPA informed the ED and DOAL that they were recently cited for a violation of CCR 87465(a)(4) on 10/01/2025. LPA informed ED and DOAL that a civil penalty in the amount of $250 is being assessed on today’s date (11/19/2025) for a repeat violation of the same licensing regulation within a twelve (12) month period. DOAL stated that med techs and nurses had been given mandatory training on 11/13/2025 which included a review of title 22 regulations regarding medication management and the importance of adhering to policies and procedures regarding medication administration/tracking.

Pursuant to Title 22 of the CA Code of Regulations, the following deficiency and civil penalty were cited (refer to LIC 809-D): Exit interview conducted with DOAL and copy of the report was issued and appeal rights provided.

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

DATE: 11/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/19/2025 01:06 PM - It Cannot Be Edited


Created By: Trevor Byrne On 11/19/2025 at 12:42 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: 11/19/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/19/2025
Section Cited
CCR
87465(a)(4)

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87465 Incidental Medical and Dental Care
(a) A plan for incidental medical and dental care shall be developed...
(4) The licensee shall assist residents with self-administered medications as needed.
This requirement is not met as evidenced by:
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The facility had conducted in-service training with the team responsible for administering R1's medications. POC cleared at the time of the visit.
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Based on record review and interview the licensee did not comply with the section cited above as R1 missed administration of their prescribed Torsemide between 09/30/2025-10/03/2025 which posed a potential health risk to clients in care.
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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: 11/19/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/19/2025


LIC809 (FAS) - (06/04)
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