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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609306
Report Date: 09/30/2025
Date Signed: 10/01/2025 09:26:07 AM

Document Has Been Signed on 10/01/2025 09:26 AM - 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:ELAINE'S PLACEFACILITY NUMBER:
197609306
ADMINISTRATOR/
DIRECTOR:		BOTE, ELAINE PFACILITY TYPE:
740
ADDRESS:22745 DOLOROSA STREETTELEPHONE:
(818) 340-7769
CITY:WOODLAND HILLSSTATE: CAZIP CODE:
91367
CAPACITY: 6CENSUS: 6DATE:
09/30/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:22 AM
MET WITH:Elaine BoteTIME VISIT/
INSPECTION COMPLETED:
04:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Angela Barutyan arrived at the facility unannounced to conduct a required annual visit at 11:22AM. LPA met with staff and Administrator Elaine Bote who arrived shortly thereafter. Entrance interview conducted.

Beginning at 11:27AM, the LPA, along with staff and Administrator, toured the physical plant areas inside and outside to ensure there are no health and safety hazards and that facility is in compliance with Title 22 Regulations. The following was observed:

KITCHEN: At 11:27AM, LPA inspected the kitchen/food service area. Kitchen appliances appeared clean and were in operable condition at the time of the visit. The facility had a sufficient supply of perishable and non-perishable food. Knives, sharps, cleaning supplies, and disinfectants are stored inaccessible in a locked cabinet.

BEDROOMS: There are six (6) single-occupancy resident bedrooms. All resident bedrooms were observed to be furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting.

BATHROOMS: There are three (3) bathrooms, two (2) are in the hallway and one (1) is attached to Bedroom #3. LPA observed bathrooms to be clean, sanitary, and in operating condition with slip-resistant surfaces and grab bars. Hot water temperatures were measured in bathrooms and were between 114.3-117.7 degrees F, which is within the required range.

Report Continued on LIC 809-C.

NAME OF LICENSING PROGRAM MANAGER: Kristin Heffernan
NAME OF LICENSING PROGRAM ANALYST: Angela Barutyan
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/30/2025
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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Document Has Been Signed on 10/01/2025 09:26 AM - It Cannot Be Edited


Created By: Angela Barutyan On 09/30/2025 at 03:12 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: ELAINE'S PLACE
FACILITY NUMBER: 197609306

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/30/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(f)
Personnel Requirements - General
(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health.Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties.

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 as two (2) staff were missing a health screening which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/14/2025
Plan of Correction
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Administrator stated staff will obtain a valid health screening and will submit proof to CCL by 10/14/2025.

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:
Angela Barutyan
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/30/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/30/2025


LIC809 (FAS) - (06/04)
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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: ELAINE'S PLACE
FACILITY NUMBER: 197609306
VISIT DATE: 09/30/2025
NARRATIVE
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COMMON AREAS: These include the living room and dining area. Common areas were appropriately furnished and in good condition. Smoke detectors and carbon monoxide detector were tested at 11:51AM and were operable. LPA observed two (2) fire extinguishers, one (1) by the laundry room which was fully charged and last serviced 09/10/2025 and one (1) in the kitchen area which was fully charged. Required posters were displayed throughout the common areas.

OUTDOOR AREA: The backyard has patio furniture and a covered area. No obstructions observed in the passageways. No bodies of water were observed. There is an outdoor storage area which contained additional supplies and a staff break area. LPA observed a staff member sleeping in the storage area however interviews stated that staff have their own room and only utilize the storage area for breaks.

MEDICATIONS: Medications review began at 11:54AM; medications are centrally stored and kept inaccessible in a locked kitchen cabinet. LPA reviewed medications for two (2) residents. At 12:15PM, LPA observed Trazadone 50mg for Resident #1 (R1) with four (4) pills unaccounted for. The centrally stored medication and destruction record (CSMDR) had the medication logged with a start date of 09/12/2025 and a quantity of 90 pills with directions to administer one (1) pill a day, however, a total of sixty-eight (68) pills were observed during the visit on 09/30/2025 instead of seventy-two (72) pills. Staff stated that the medication may have been incorrectly filled by the pharmacy and the quantity received may have been off, however, no documentation could be provided.

RECORD REVIEW: LPA began record review at 12:55PM. LPA reviewed six (6) out of six (6) resident files for documents including, but not limited to: appraisals, medical records, admissions agreement, and consent forms. Four (4) out of six (6) resident files were missing updated appraisals. Administrator completed the reappraisals during the visit. LPA reviewed three (3) personnel files for documents including, but not limited to: personnel record (LIC 501), health assessments/screening (LIC 503), TB test, criminal record clearances, active first aid/CPR training, and appropriate training. LPA observed two (2) out of three (3) staff missing criminal record clearance, LIC501, and LIC503. During the visit, staff left to obtain criminal record clearance and Administrator stated that the two (2) staff will not resume work until receiving background clearance. Administrator stated that facility will have staff coverage.

Report Continued on LIC 809-C.

NAME OF LICENSING PROGRAM MANAGER: Kristin Heffernan
NAME OF LICENSING PROGRAM ANALYST: Angela Barutyan
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2025
LIC809 (FAS) - (06/04)
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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: ELAINE'S PLACE
FACILITY NUMBER: 197609306
VISIT DATE: 09/30/2025
NARRATIVE
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INFECTION CONTROL/EMERGENCY DISASTER PLANNING: During today’s visit, the LPA reviewed the facility's infection control practices. The facility’s policies and procedures as it pertains to infection control are adequate. Emergency disaster plan is updated annually as required. Emergency disaster drill was conducted on 09/01/2025.

The following deficiencies were observed (See LIC 809-D) and cited from the California Code of Regulations, Title 22 and/or California Health and Safety Code. Civil penalty was issued in the amount of $1000 for criminal record clearance. Administrator was informed that failure to correct deficiencies may result in additional civil penalties.

Exit interview conducted. The report was reviewed during the visit. A copy of the appeal rights and report were provided via email and postal mail on 10/01/2025 for signatures due to technical difficulties during the visit.

NAME OF LICENSING PROGRAM MANAGER: Kristin Heffernan
NAME OF LICENSING PROGRAM ANALYST: Angela Barutyan
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/01/2025 09:26 AM - It Cannot Be Edited


Created By: Angela Barutyan On 09/30/2025 at 03:36 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: ELAINE'S PLACE
FACILITY NUMBER: 197609306

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/30/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87355(e)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility:

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 as two (2) staff members were missing a criminal record clearance which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/01/2025
Plan of Correction
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Staff submitted a live scan application during the visit. Administrator stated staff will not work until obtaining background clearance. Administrator obtained staff coverage in the meantime and will submit proof of background clearance once complete.
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:
Angela Barutyan
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/30/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/30/2025


LIC809 (FAS) - (06/04)
Page: 6 of 8
Document Has Been Signed on 10/01/2025 09:26 AM - It Cannot Be Edited


Created By: Angela Barutyan On 09/30/2025 at 03:36 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: ELAINE'S PLACE
FACILITY NUMBER: 197609306

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/30/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(h)(4)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (4) All centrally stored medications shall be labeled and maintained in compliance with state and federal laws. No persons other than the dispensing pharmacist shall alter a prescription label.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on medication review, the licensee did not comply with the section cited above as there were four (4) pills for Resident #1 that were unaccounted for which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/14/2025
Plan of Correction
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Administrator stated they will provide additional medication training to staff and will submit proof by the due date 10/14/2025.
Type B
Section Cited
CCR
87463(a)
Reappraisals
(a) The pre-admission appraisal, as specified in Section 87457, Pre-Admission Appraisal, shall be updated, in writing as frequently as necessary or once every 12 months, whichever occurs first, to note significant changes in condition, as defined in Section 87101, Definitions, and to keep the appraisal accurate. For the purposes of this section, the updated pre-admission appraisal shall be referred to as the reappraisal.

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 as four (4) out of six (6) resident files were missing updated reappraisals which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/14/2025
Plan of Correction
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Administrator completed the reappraisals during the visit and stated they will submit proof after reviewing the reappraisals with the residents and/or their responsible parties. Administrator will submit proof to CCL by 10/14/2025.
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:
Angela Barutyan
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/30/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/30/2025


LIC809 (FAS) - (06/04)
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