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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608972
Report Date: 06/12/2025
Date Signed: 06/13/2025 01:13:35 PM

Document Has Been Signed on 06/13/2025 01:13 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:ANTHEM SENIOR CAREFACILITY NUMBER:
197608972
ADMINISTRATOR/
DIRECTOR:		GHAZARYAN, SOFIAFACILITY TYPE:
740
ADDRESS:12813 FRIAR STREETTELEPHONE:
(818) 445-0993
CITY:NORTH HOLLYWOODSTATE: CAZIP CODE:
91606
CAPACITY: 6CENSUS: 5DATE:
06/12/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Sofia GhazaryanTIME VISIT/
INSPECTION COMPLETED:
05:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Valeria Conway arrived at the facility unannounced to conduct a required annual visit at 9:30 a.m. When the LPA arrived, there was one staff present. The LPA was greeted by Caregiver, Armenuhi Ahadzhanian and informed the reason for the visit. Caregiver contacted the Administrator by phone, Sofia Ghazaryan. At 10:17 A.M. administrator arrived at the facility. LPA explained the reason for the visit.

At 10:25 A.M. the LPA, along with administrator, 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.

Facility is a single-story residence that consists of four (4) resident bedrooms and two (2) bathrooms. There is one (1) additional bedroom and bathroom for staff use. The facility serves residents with dementia, the auditory alarms on the exit doors were tested and functioned properly at the time of visit.

Bedrooms: All resident resident’s bedrooms were properly furnished with at least one chair, a bed, night stand, chests of drawers, and sufficient lighting for each resident. The bedrooms had appropriate and adequate bedding and linens such as sheets, pillowcases, mattress pads, and blankets. In addition, no bedroom was used as a passageway to another room, bath, or toilet. All rooms were free of odors. All window screens were clean and maintained in good repair.



Continued on LIC 809-C
NAME OF LICENSING PROGRAM MANAGER: Desaree Perera
NAME OF LICENSING PROGRAM ANALYST: Valeria Conway
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 06/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/12/2025
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 11
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)
Page: 2 of 11
Document Has Been Signed on 06/13/2025 01:13 PM - It Cannot Be Edited


Created By: Valeria Conway On 06/12/2025 at 04:17 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: ANTHEM SENIOR CARE
FACILITY NUMBER: 197608972

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/12/2025

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 and record review, the licensee did not comply with the section cited above by having bedridden resident (Resident #1 -R1) in room #2 and non-ambulatory resident (R2) in room #1 and Resident #5 (R5) in the former activity room which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/13/2025
Plan of Correction
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Administrator agrees to contact the fire inspector tomorrow and get a new fire clearance conducted. Also, administrator will write a statement of understanding regarding section CCR 87202(a)
Type A
Section Cited
CCR
87309(a)
Storage Space and Access
(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage.

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 by having the magnetic lock on the drawer where sharps are kept not functioning properly and failed to keep drawer securely locked which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/13/2025
Plan of Correction
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Administrator agrees to replace magnetic lock by POC due date and send proof to LPA.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Desaree Perera
NAME OF LICENSING PROGRAM MANAGER:
Valeria Conway
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/12/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/12/2025


LIC809 (FAS) - (06/04)
Page: 3 of 11
Document Has Been Signed on 06/13/2025 01:13 PM - It Cannot Be Edited


Created By: Valeria Conway On 06/12/2025 at 04:17 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: ANTHEM SENIOR CARE
FACILITY NUMBER: 197608972

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/12/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(a)(4)
Incidental Medical and Dental Care Services
(4) The licensee shall assist residents with self-administered medications as needed.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above not administering prescribed medication as need it, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/13/2025
Plan of Correction
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Administrator agrees to contact a third-party agency to conduct medication training including how to use the centrally stored medication and destruction log. Also, administrator will write a statement of understanding regarding section CCR 87465(a)(4).
Type A
Section Cited
CCR
87606(c)
Care of Bedridden Residents
(c) To accept or retain a person who is bedridden, other than for a temporary illness or recovery from surgery, a licensee shall obtain and maintain an appropriate fire clearance as specified in Section 87202, Fire Clearance.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above by having R1 in a non approved bedridden room which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/13/2025
Plan of Correction
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Administrator agrees to contact the fire inspector tomorrow and get a new fire clearance conducted or movce R1 to room #3 before 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.
Desaree Perera
NAME OF LICENSING PROGRAM MANAGER:
Valeria Conway
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/12/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/12/2025


LIC809 (FAS) - (06/04)
Page: 4 of 11
Document Has Been Signed on 06/13/2025 01:13 PM - It Cannot Be Edited


Created By: Valeria Conway On 06/12/2025 at 04:17 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: ANTHEM SENIOR CARE
FACILITY NUMBER: 197608972

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/12/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87615(a)(5)
Prohibited Health Conditions
(a) Persons who require health services for or have a health condition including, but not limited to, those specified below shall not be admitted or retained in a residential care facility for the elderly: (5) Residents who depend on others to perform all activities of daily living for them as set forth in Section 87459, Functional Capabilities.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above by having a resident unable to care for themselves which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/16/2025
Plan of Correction
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Administrator agrees to submit a waiver to CCL by POC due date or to have resident's physician report updated or get hospice services for R1.
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.
Desaree Perera
NAME OF LICENSING PROGRAM MANAGER:
Valeria Conway
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/12/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/12/2025


LIC809 (FAS) - (06/04)
Page: 5 of 11
Document Has Been Signed on 06/13/2025 01:13 PM - It Cannot Be Edited


Created By: Valeria Conway On 06/12/2025 at 04:17 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: ANTHEM SENIOR CARE
FACILITY NUMBER: 197608972

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/12/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.618(c)(3)
Other Provisions
(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.

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 by not having CPR First Aid certificate on record for all staff which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/26/2025
Plan of Correction
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Administrator agrees to hav all staff trained by POC due date.
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above by not conducting quarterly emergency drills which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/26/2025
Plan of Correction
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Administrator agreed to conduct an emergency drill before POC due date and submit proof to LPA.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Desaree Perera
NAME OF LICENSING PROGRAM MANAGER:
Valeria Conway
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/12/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/12/2025


LIC809 (FAS) - (06/04)
Page: 6 of 11
Document Has Been Signed on 06/13/2025 01:13 PM - It Cannot Be Edited


Created By: Valeria Conway On 06/12/2025 at 04:17 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: ANTHEM SENIOR CARE
FACILITY NUMBER: 197608972

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/12/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87608(a)(5)(B)
Postural Supports
(B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above by not having physician’s order showing bedrails are required which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/12/2025
Plan of Correction
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Administrator was able to provide proof during today's visit. POC Cleared.
Type B
Section Cited
CCR
87632(a)(4)
Hospice Care Waiver
(4) A statement by the licensee that an agreement with the hospice agency will be entered into regarding the care plan for the terminally ill resident to be accepted and/or retained in the facility. The agreement with hospice shall design and provide for the care, services, and necessary medical intervention related to the terminal illness as necessary to supplement the care and supervision provided by the licensee.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review)], the licensee did not comply with the section cited above by not having hospice care plan for resident in care which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/19/2025
Plan of Correction
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Administrator submitted care plan for resident in care. POC cleared.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Desaree Perera
NAME OF LICENSING PROGRAM MANAGER:
Valeria Conway
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/12/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/12/2025


LIC809 (FAS) - (06/04)
Page: 7 of 11
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: ANTHEM SENIOR CARE
FACILITY NUMBER: 197608972
VISIT DATE: 06/12/2025
NARRATIVE
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Continued from LIC 809

Bathrooms: LPA observed all bathrooms were clean, properly supplied and had functional fixtures. The LPA observed grab bars and slip resistant floors in all bathrooms. Residents have sufficient amounts of supplies for personal hygiene. Between 10:31 A.M. and 10:45 A.M. hot water was measured in all residents’ bathrooms. All bathrooms were within the required limit of 105-120 degrees Fahrenheit.

Common Areas: These included the living room and dining area. The common areas were checked for cleanliness and furniture was checked for functionality during time of visit. The facility maintained a comfortable temperature of 74 degrees. The LPA observed the required postings in the entry way and common sitting area. Combination smoke alarms and carbon monoxide detectors were tested at 3:02 P.M. and were operational at this time. LPA observed a fully charged fire extinguisher serviced on 10/23/2023. Technical violation issued under maintenance and operations. LPA observed cameras in common areas.



Kitchen: The kitchen appeared clean and the appliances and fixtures functional during the time of visit. LPA observed a sufficient amount of perishable and non-perishable food at the facility. Sharp objects were stored in a kitchen drawer located to the right of the oven. During today’s visit, the magnetic lock on the drawer was not functioning properly and failed to keep drawer securely locked. The administrator stated that the lock is malfunctioning and acknowledged that it needs to be replaced. Furthermore, LPA observed a glass cup containing stainless steel knifes stored inside an unlocked kitchen cabinet. Additionally, an unlocked medication injection was observed inside the kitchen refrigerator. At 10:53 A.M. hot water measured at 105.7 degrees Fahrenheit.

Garage: The facility has converted the garage into a separate living space which has its own address.



Continued on LIC 809-C
NAME OF LICENSING PROGRAM MANAGER: Desaree Perera
NAME OF LICENSING PROGRAM ANALYST: Valeria Conway
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/12/2025
LIC809 (FAS) - (06/04)
Page: 8 of 11
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: ANTHEM SENIOR CARE
FACILITY NUMBER: 197608972
VISIT DATE: 06/12/2025
NARRATIVE
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Continued from LIC 809-C

Surrounding Grounds (Outdoors): The backyard has a covered outdoor area equipped with furniture for resident use and a small laundry area. There were no bodies of water noted. The front yard is free of obstructions, the side gate has a self-latching door. Additionally, the LPA observed a back house with two (2) rooms. Upon entering the first room, the LPA observed that it was being used as an office and storage area. The room contained extra food supplies, a refrigerator, and emergency food and water provisions. LPA conducted a review of expiration dates on product labels. The LPA observed that three (3) items were past their expiration date. Administrator discarded all three (3) items during today’s visit. Technical Advice Issued. The second room was locked, however, upon entry, the LPA observed that it contained chemical supplies, tools, and various decorations.

File review: A review of facility files was initiate at 11:23 A.M. and the following was observed. LPA reviewed five (5) of five (5) residents files and three (3) staff file including the administrator’s. Files were reviewed for, but not limited to: Physician's Reports, Personal Rights, Admission Agreements, staff training records, health screenings, TB tests, and background clearance. Record review of resident files revealed that Resident #1’s (R1)’s physicians report, dated 02/04/2024 indicating R1 not having capacity for selfcare and R1 is neither under hospice care nor have an approved exception on file with the Department. Furthermore, LPA observed that of the five (5) residents currently residing at the facility, three (3) are non-ambulatory, one (1) is bedridden and one (1) is ambulatory.

Continued on LIC 809-C
NAME OF LICENSING PROGRAM MANAGER: Desaree Perera
NAME OF LICENSING PROGRAM ANALYST: Valeria Conway
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/12/2025
LIC809 (FAS) - (06/04)
Page: 9 of 11
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: ANTHEM SENIOR CARE
FACILITY NUMBER: 197608972
VISIT DATE: 06/12/2025
NARRATIVE
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Continued from LIC 809-C

The facility’s fire clearance on file, dated on 01/05/2016, only authorizes care for four (4) ambulatory residents, one (1) non-ambulatory and one (1) bedridden resident. According to the clearance, only Room #3 is approved to accommodate residents who are non-ambulatory or bedridden. During the plant tour, LPA observed that bedridden resident (Resident #1 -R1) was placed in room #2, non-ambulatory resident (R2) was placed in room #1, and Resident #5 (R5) was placed in the former activity room which are not designated for such use. The Administrator stated that a new fire clearance was granted in 2023, however, she was unable to present the document at the time of the visit. LPA attempted to contact the fire inspector to verify the updated clearance but was unable to confirm this information. Also, LPA observed R3 did not have a current hospice care plan on file. Additionally, R2 and R3 were observed to have full bed rails installed on their beds, however, there were no physician’s orders were on record. Administrator was able to provide this information during today’s visit. Furthermore, R1, a former hospice patient who is no longer under hospice care was observed to have f ull bed rails in place. No current physician’s order was available to support the continued used of the full bedrails. During staff record review, LPA observed that Administrator (Ad), Staff #1 (S1) and Staff #2 (S2) did not have current CPR/First aid certificate. The administrator is the SSI payee for R1 and surety bond is current.

LPA requested last emergency drill; however, Administration was unable to provide it. LPA obtained Client Roster, Personnel Report, liability insurance and updated facility Sketch.

Continued on LIC 809-C
NAME OF LICENSING PROGRAM MANAGER: Desaree Perera
NAME OF LICENSING PROGRAM ANALYST: Valeria Conway
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/12/2025
LIC809 (FAS) - (06/04)
Page: 10 of 11
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: ANTHEM SENIOR CARE
FACILITY NUMBER: 197608972
VISIT DATE: 06/12/2025
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Continued from LIC 809-C

Medication Audit: Medications review began at 3:24 P.M. medications are centrally stored and locked in a cabinet in the kitchen. Medications are labeled and checked for expiration dates. Medications were not properly documented on the centrally stored medications and destruction record. LPA observed errors during the medication review where date started and pill count did not match.

Pursuant to Title 22, California Code of Regulations and/or CA Health and Safety Code, the following deficiencies were cited (refer to LIC 809-D.) Administrator was informed that failure to correct the deficiencies may result in civil penalties.

An immediate civil penalty of $500 is assessed today due to being cited for fire clearance. Administrator was informed that additional civil penalties might be assessed based on Health and Safety Code 1569.49(e) and 1569.49(f).



Exit interview conducted, appeal rights discussed, and a copy of this report and appeal rights were provided.
NAME OF LICENSING PROGRAM MANAGER: Desaree Perera
NAME OF LICENSING PROGRAM ANALYST: Valeria Conway
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/12/2025
LIC809 (FAS) - (06/04)
Page: 11 of 11