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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609340
Report Date: 09/17/2025
Date Signed: 09/17/2025 11:42:07 AM

Document Has Been Signed on 09/17/2025 11:42 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 S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:JACKIE'S HIDEAWAY AFACILITY NUMBER:
197609340
ADMINISTRATOR/
DIRECTOR:		TAL, TALYFACILITY TYPE:
740
ADDRESS:5925 DONNA AVETELEPHONE:
(818) 345-6752
CITY:TARZANASTATE: CAZIP CODE:
91356
CAPACITY: 6CENSUS: 6DATE:
09/17/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:40 AM
MET WITH:Margarita PizaTIME VISIT/
INSPECTION COMPLETED:
11:40 AM
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At approximately 8:40 a.m. on 09/17/25 Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced annual visit. LPA met with staff and disclosed the reason for the visit.

The facility was last visited on 09/27/24 for an annual visit. It is a single story building with six (06) bedrooms, five (05) bathrooms, kitchen, common areas, and outdoor areas. It has an approved fire clearance for six (06) non-ambulatory residents, of which one (01) may be bedridden. The facility serves residents with dementia. Approved hospice waivers for six (06). Surveillance cameras are used in exterior areas.

The front entrance was gated and unlocked from the inside. Staff permitted entry through a remote control. The front yard was maintained. At the front door, LPA observed postings for the house rules, visitation policy, facility sketch, facility license, COVID precautions, rights of resident councils, neighborhood grievance procedure, ombudsman contacts, and oxygen in use signs. Additional postings were observed for the emergency disaster plan, personal rights, and administrator certificates. A screening station at the front contained a visitor log and hand sanitizer.

Walls, floors, windows, screens, and blinds were clean and in good repair. A fireplace in the living room was appropriately covered. At 9:00 a.m. LPA observed a fully charged fire extinguisher near the main entrance. It was fully-charged and purchased on 09/15/25 with a receipt attached. The living room contained a television, reading materials, and furniture in good repair. The dining room contained furniture in good repair, board games, puzzles, and art supplies. At 9:10 a.m. the house telephone was called and deemed operational. At 9:15 a.m. LPA measured the room temperature to be 77 degrees Fahrenheit. At approximately 9:20 a.m., carbon monoxide and smoke detectors were tested and operational. At 9:25 a.m. LPA observed a fully-stocked first aid kit in the kitchen.

NAME OF LICENSING PROGRAM MANAGER: Naira Margaryan
NAME OF LICENSING PROGRAM ANALYST: Nicholas Reed
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/17/2025
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 S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: JACKIE'S HIDEAWAY A
FACILITY NUMBER: 197609340
VISIT DATE: 09/17/2025
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LPA observed an adequate supply of perishable and non-perishable foods in the kitchen refrigerator, freezer, and pantry. Emergency food and water supplies were observed in the pantry. Appliances were in good condition. Sharps and cleaning solutions were locked below the sink. Medications were locked above the counter top. At 9:30 a.m., a medication review was conducted with Staff #1 (S1). All medications reviewed were maintained in the correct quantities.

The laundry area was near the kitchen and contained a washing machine and a dryer in working order. Detergents were locked above them in a cabinet. An office area near the laundry area contained locked confidential files. Eight (08) out of eight (08) auditory alarms were on and functional. The seating area in the rear was shaded. The back yard also contained a gardened area. A storage shed was locked and contained tools and extra supplies. Two (02) out of two (02) emergency exit paths were free of hazards. The exit gate was unlocked.

The facility had six (06) bedrooms. All bedrooms contained a chair, lamp, nightstand, storage, and a bed with adequate bedding. All furnishings were clean and in good condition. Exit doors from rooms were unlocked. The facility had five (05) bathrooms. Four (04) were private bathrooms, and one (01) was shared. Bathrooms contained liquid soap, trash cans with tight fitting lids, grab bars near the toilet and shower, and a non-skid mat in the shower. At approximately 10:35 a.m. LPA measured the water temperature to be 119.2 degrees Fahrenheit in the private bathroom to Bedroom #3.

At approximately 10:40 a.m. LPA conducted a records review of resident and personnel files. All files were complete and available for audit.

During today’s inspection, no immediate health or safety hazards were observed.

Exit interview conducted. Copy of report provided.

NAME OF LICENSING PROGRAM MANAGER: Naira Margaryan
NAME OF LICENSING PROGRAM ANALYST: Nicholas Reed
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2025
LIC809 (FAS) - (06/04)
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