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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609097
Report Date: 06/16/2025
Date Signed: 06/16/2025 06:11:33 PM

Document Has Been Signed on 06/16/2025 06:11 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:THREE C'S CARE HOMEFACILITY NUMBER:
197609097
ADMINISTRATOR/
DIRECTOR:		LOPEZ, MILAGROSFACILITY TYPE:
740
ADDRESS:6447 BABCOCK AVENUETELEPHONE:
(818) 747-2212
CITY:NORTH HOLLYWOODSTATE: CAZIP CODE:
91606
CAPACITY: 6CENSUS: 4DATE:
06/16/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:36 AM
MET WITH:Milagros Lopez, AdministratorTIME VISIT/
INSPECTION COMPLETED:
06:15 PM
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Licensing Program Analyst (LPA) Christine Yee conducted an unannounced required Annual Inspection using the complete CARE Inspection Tool and met with Milagros Lopez, Administrator. The reason for today's visit was provided.

The facility is a single storey family home consisting of a living room, dining room, kitchen, three bedrooms, a private bathroom, a common bathroom and a detached garage. The facility is fire cleared for five(5) non-ambulatory and one(1) bedridden. Bedroom #3 is designated for bedridden use.

The following was observed during today's visit:
  • The living room and dining room was furnished with the appropriate furniture for 6 residents.
  • The kitchen was equipped with a stove, microwave, a dishwasher and a refrigerator. Also observed were various appliances such as rice cooker, air fryer and water cooler. Located inside the kitchen is the laundry closet that houses the washer and dryer. The only fire extinguisher purchased on 3/1/25 is also mounted in the kitchen. Sufficient perishable foods for a minimum of 2 days and non-perishable foods for a minimum of 7 days was observed on the premises. Knives and the sharps container are locked in a kitchen drawer, Medications are stored in a locked kitchen cabinet, cleansing solutions are stored in a locked cabinet under the kitchen sink.
  • All 3 resident bedrooms was furnished with 2 beds, 2 night stands, 2 lamps, 2 folding chairs, a shared set of drawers and a built in closet. The appropriate bed linens were observed on all the beds except for the hospital bed in bedroom #3. Per the Administrator, the resident does not want a flat sheet or blanket
NAME OF LICENSING PROGRAM MANAGER: Kristin Heffernan
NAME OF LICENSING PROGRAM ANALYST: Christine Yee
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 06/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/16/2025
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 5
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: THREE C'S CARE HOME
FACILITY NUMBER: 197609097
VISIT DATE: 06/16/2025
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  • and prefers the comforter. Bedroom #3 also has a sliding glass door that leads to the back yard. The auditory device was not operational when tested.
  • Located inside bedroom #3 is a private bathroom equipped with a shower stall, grab bars, a slip resistant mat, a toilet and a single sink vanity. Shampoos, deodorants and other hygiene products are stored in locked drawers. The water temperature was tested and read 106.6 degrees Fahrenheit.
  • The common bathroom, located by bedroom #1 was equipped with a bath tub/shower, a toilet and a single sink vanity. Grab bars were observed in the shower and by the toilet. A slip resistant mat and chair was observed in the shower. The water temperature was tested and read 112.6 degrees Fahrenheit. Additional hygiene products such as toothpaste, lotions were observed in the locked cabinet under the sink. Bath towels and extra linens were observed in a cabinet above the toilet.
  • The hardwired smoke detectors located in all 3 bedrooms, hallway, living room and kitchen were tested and were operational.
  • The only carbon monoxide detector located on the living room wall was also tested and was operational.
  • The auditory device on the front door was not operational
  • The first aid kit was inspected and had the required gauzes, strips, tweezer, scissors and an external thermometer. No first aid manual was observed.
  • All active staff have current first aid/CPR training. All inactive staff are to obtain current first aid/CPR training prior to working alone with the residents.
  • The facility has current general liability insurance that meets the required limits of $1 million per occurrence and $3 million total annual aggregate.
  • The backyard was observed to have a table and chairs and an umbrella for shade. The hospital bed, head and foot board, fruit picker, discarded wood needs to be thrown out or stored away.
  • Per the Administrator, the converted garage located in the back is used for storage of supplies. It is unknown if permits were obtained for the conversion and may not be inhabited by staff or residents.
  • Trash cans were observed to be tightly sealed.
  • The front yard was observed with a table and 4 chairs.

Deficiencies were cited under California Code of Regulations, Title 22, Division 6, Chapter 8

Exit interview was conducted, Appeals Rights discussed and a copy was provided.
NAME OF LICENSING PROGRAM MANAGER: Kristin Heffernan
NAME OF LICENSING PROGRAM ANALYST: Christine Yee
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2025
LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 06/16/2025 06:11 PM - It Cannot Be Edited


Created By: Christine Yee On 06/16/2025 at 05:17 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: THREE C'S CARE HOME
FACILITY NUMBER: 197609097

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/16/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87705(d)
87705 Care of Persons with Dementia
d) The licensee shall ensure that the facility has an auditory device or other staff alert feature to monitor exits on exterior doors and perimeter fence gates accessible to those residents who may be at risk for elopement, as defined in Section 87101, Definitions


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 per tour of the facility, the two outside exiting doors - the front door and the sliding glass doors located in the back have auditory devices mounted on the doors but were not operational when tested, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/23/2025
Plan of Correction
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The LIcensee will test the auditory devices currently mounted on the front and back door to see if the devices need to be replaced or if the batteries need to be replaced to ensure that the devices are operational, Licensee will self certify that the devices have been inspected and that the devices are operational by 6/23/25.
Type B
Section Cited
CCR
87465(a)(8)(A)
87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: 8) If a facility has no medical unit on the grounds, a complete first aid kit shall be maintained and be readily available in a specific location in the facility. The kit shall be a general type approved by the American Red Cross, or shall contain at least the following: (A) A current edition of a first aid manual approved by the American Red Cross, the American Medical Association or a state or federal health agency
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 when the first aid manual was requested, the Administrator indicated that they did not have one and was not aware that one was needed, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/23/2025
Plan of Correction
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The Licensee will purchase a current edition of the first aid manual approved by the American Red Cross, the American Medical Association or a state of federal health agency and maintain at the facility by POC date - 6/23/25
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Kristin Heffernan
NAME OF LICENSING PROGRAM MANAGER:
Christine Yee
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/16/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/16/2025


LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 06/16/2025 06:11 PM - It Cannot Be Edited


Created By: Christine Yee On 06/16/2025 at 05:36 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: THREE C'S CARE HOME
FACILITY NUMBER: 197609097

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/16/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
87303 Maintenance and Operation
(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.


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, per tour of the facility, the outside areas need general maintenance to remove or store all discarded items such as the hospital bed, wood, head and foot board, fruit picker, brooms, dust pans and clothes rack that are stored by the garage and behind the garageifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/23/2025
Plan of Correction
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Licensee will provide evidence that the hospital bed, head and foot board, brooms, dust pans and wood that stored behind the garage and by the garage have been removed or stored away by POC 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.
Kristin Heffernan
NAME OF LICENSING PROGRAM MANAGER:
Christine Yee
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/16/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/16/2025


LIC809 (FAS) - (06/04)
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