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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609057
Report Date: 03/12/2026
Date Signed: 03/12/2026 03:03:13 PM

Document Has Been Signed on 03/12/2026 03:03 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.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:PRIMROSE 2FACILITY NUMBER:
197609057
ADMINISTRATOR/
DIRECTOR:		NINO SMITHFACILITY TYPE:
740
ADDRESS:8115 DE SOTO AVETELEPHONE:
(323) 387-2755
CITY:CANOGA PARKSTATE: CAZIP CODE:
91304
CAPACITY: 6CENSUS: 5DATE:
03/12/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:45 AM
MET WITH:Nino Smith - AdministratorTIME VISIT/
INSPECTION COMPLETED:
02:15 PM
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At 9:45am, Licensing Program Analyst (LPA) Perchui Milena Khurshudyan conducted an unannounced required annual visit. LPA met with staff, later Administrator Nino Smith arrived and disclosed the reason for the visit. LPA and Administrator toured the facility inside and out.

The facility is a single-story building with 7 bedrooms, 3 bathrooms, kitchen, common areas, and outdoor areas. It has an approved fire clearance for six (6) residents, of which 6 may be non-ambulatory, of which all 6 residents can be bedridden. The facility serves residents with dementia. Approved hospice waivers for 6 residents.

Kitchen: At approximately 10:50am, LPA toured the kitchen area and observed enough supplies of staple non-perishable for minimum 1 week and perishable for 2 days at the facility. Kitchen surfaces were sanitary, and all appliances were functional. Sharps were locked below the counter, and cleaning solutions were locked in separate cabinet in the kitchen. LPA observed a fully charged fire extinguisher in the kitchen. It was last inspected on 9/9/2025.

Medications: At approximately 12:45pm, LPA observed medications are centrally stored and locked inside the kitchen cabinet. LPA also observed an additional locked cabinet where resident and staff files are kept.

Bedrooms: LPA observed total of seven (7) bedrooms of which six (6) are designated for residents’ use. All bedrooms are properly furnished, clean and have appropriate bedding and linens. Facility has awake staff.

Bathrooms: LPA observed five (5) bathrooms, and all bathrooms appeared to be clean and in good repair. Properly supplied with toilet paper, soap and paper towels. LPA observed appropriate grab bar and all bathrooms had non-skid mats. LPA observed appropriate hand-washing signs posted in each bathroom. At 11:15am, hot water temperature measured at 107.4°F. Continue on LIC809-C

NAME OF LICENSING PROGRAM MANAGER: Nichelle Gillyard
NAME OF LICENSING PROGRAM ANALYST: Perchui Khurshudyan
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 03/12/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/12/2026
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.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: PRIMROSE 2
FACILITY NUMBER: 197609057
VISIT DATE: 03/12/2026
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Common Areas: The facility maintains a comfortable temperature at 73°F. The living room and dining area appeared clean and were properly furnished. The living room has a television, and comfortable furniture. No obstructions or tripping hazards throughout the facility. LPA observed an operable washer and dryer placed inside the locked garage. All detergents were also stored and locked. Extra emergency food and water was also readily available for residents in care.

Smoke detectors/carbon monoxide. At 12:55pm, LPA tested the dual-function smoke and carbon monoxide detector to be operational. When tested, 3 out of 3 detectors functioned simultaneously, and the fire door closed.

Outside areas: At approximately 11:35am LPA toured the outside area of the facility. LPA observed appropriate outdoor furniture, with a covered shaded area for residents. There is no bodies of water or swimming pool at the facility. All emergency exit paths were free from obstructions. Exit gates were unlocked.

Between 11:00am to 12:45pm, LPA reviewed records of six (6) residents and four (4) staff. Resident and staff records appeared to be complete and updated.

LPA reviewed Centrally Stored Medication Destruction Records for proper documentation. Facility also maintains Medical Administration Records (MAR). LPA observed centrally stored medication, and First Aid kit locked in the commercial cabinet and inaccessible to clients in care. LPA observed First-aid kit is complete and has new manual. PRN medications have written orders from a physician.

During CSMDR / MAR / Medication review, LPA conducted medication count and noted Resident #4’s (R4) medication quantities on hand did not match the amounts listed on the CSMDR order.

Potentially dangerous items are kept inaccessible to residents in care. Facility operates with two (2) shifts and has two (2) staff members for each shift.

An emergency exit plan/sketch is posted on the wall along with other posting requirements.


LPA interviewed the Administrator and two (2) Caregivers, one (1) resident who agreed to answer questions.
LPA collected LIC500, LIC9020, Certificate of Liability Insurance.
The Administrator's certificate - Exp date is 12/5/2026.
Citation issued during today's visit, see LIC809-D.
Exit interview conducted and copy of this report signed and delivered.
NAME OF LICENSING PROGRAM MANAGER: Nichelle Gillyard
NAME OF LICENSING PROGRAM ANALYST: Perchui Khurshudyan
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/12/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2026
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/12/2026 03:03 PM - It Cannot Be Edited


Created By: Perchui Khurshudyan On 03/12/2026 at 01:34 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., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: PRIMROSE 2
FACILITY NUMBER: 197609057

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/12/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(c)(2)
87465 Incidental Medical and Dental Care Services(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (2) Once ordered by the physician the medication is given according to the physician's directions.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observation and records review, Resident #4’s (R4) medication quantities on hand did not match the amounts listed on the CSMDR order, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/13/2026
Plan of Correction
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The Administrator/Licensee will schedule and provide complete Medication training to all staff members and provide proof of training materials to LPA 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.
Nichelle Gillyard
NAME OF LICENSING PROGRAM MANAGER:
Perchui Khurshudyan
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 03/12/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/12/2026


LIC809 (FAS) - (06/04)
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