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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609495
Report Date: 12/08/2025
Date Signed: 12/08/2025 05:07:42 PM

Document Has Been Signed on 12/08/2025 05:07 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:WOODLAKE LOVING CARE LLCFACILITY NUMBER:
197609495
ADMINISTRATOR/
DIRECTOR:		ARDAKANI, SHAKILAFACILITY TYPE:
740
ADDRESS:8016 WOODLAKE AVETELEPHONE:
(818) 217-6778
CITY:WEST HILLSSTATE: CAZIP CODE:
91304
CAPACITY: 6CENSUS: 6DATE:
12/08/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Shakila Ardakani - Administrator TIME VISIT/
INSPECTION COMPLETED:
05:30 PM
NARRATIVE
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On 12/8/25, Licensing Program Analysts (LPAs) Perchui Milena Khurshudyan and Tihesha Smith, conducted an unannounced Case Management visit to this facility. Upon arrival LPAs met with Shakila Ardakani Administrator and explained the reason for the visit. The purpose of today’s visit is to evaluate R1’s health condition, care plan, and the facility’s improper assessment practices related to R1’s return from the hospital.

At approximately 10:50am, LPAs conducted a brief physical plant tour to ensure health and safety of the residents are protected. No health and safety hazards noted during the visit.
On 10/17/25, LPA Khurshudyan received an Incident Report (IR) regarding R1, who developed wound on the right toe and per home health nurse evaluation R1 required antibiotic. On 10/23/25, LPA received another Incident Report regarding R1 being transferred to hospital due to wound infection on the toe. LPA contacted the Administrator for additional information regarding R1’s health condition. During phone conversation with the Administrator, LPA requested R1’s home health nurse visit notes, medical evaluation reports, hospital records, and informed the Administrator that to continue providing care under home health agency in the facility, the department will need an Exception Letter with care plan details before discharging R1 back to the facility with higher than stage 2 pressure ulcer.
On 11/25/25, LPA received R1’s hospital discharge records and Home Health agency visit reports via email and revealed that R1 was discharged from the hospital back to the board and care on 10/28/25, with assigned home health care.
According to discharge records, Resident 1 (R1) was diagnosed with a unspecified pressure wound (no stage noted) on the right fifth toe and sepsis in the body. The records note the presence of an infection, but do not indicate whether the infection had spread or become persistent."
Continue on LIC809-C
NAME OF LICENSING PROGRAM MANAGER: Nichelle Gillyard
NAME OF LICENSING PROGRAM ANALYST: Perchui Khurshudyan
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 12/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/08/2025
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.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: WOODLAKE LOVING CARE LLC
FACILITY NUMBER: 197609495
VISIT DATE: 12/08/2025
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At the time of this visit LPAs spoke with the Administrator and the Administrator acknowledged that R1 was readmitted back to the facility while was getting antibiotics for unspecified infection through the IV Pick line. The Administrator verified that prior to readmission, she failed to contact Licensing Office to request an exception to readmit and/or retain the resident with the health conditions requiring higher level of care.
LPAs spoke with the Administrator and informed them the time if resident’s readmission on 10/28/25 the facility was operating in major noncompliance with Title 22 Regulations that posed an immediate risk to R1’s health and safety.

Based on today’s inspection, observation and record review, the following deficiencies were cited and recorded on LIC809D.

During exit interview, the Administrator was informed that immediate Civil Penalty will be issued for readmission and retention of the resident with prohibited health condition.

Deficiencies issued during today’s visit, check LIC809D pages.

Exit interview conducted, 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: 12/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/08/2025
LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 12/08/2025 05:07 PM - It Cannot Be Edited


Created By: Perchui Khurshudyan On 12/08/2025 at 04:41 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: WOODLAKE LOVING CARE LLC
FACILITY NUMBER: 197609495

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/08/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/09/2025
Section Cited
CCR
87455(c)(2)

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Acceptance and Retention Limitations (c)No resident shall be accepted or retained if any of the following apply:
(2) The resident requires 24-hour, skilled nursing or intermediate care […]
This requirement was not met as evidenced by:
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The resident is no longer receiving IV PICC line therapy.
Verification of scheduled training need to be submitted to LPA by POC due date 12/09/25.
Training materials will need to be submitted later after comlition.
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Based on observations, records review and interview, the administrator revealed that R1 was re-admitted to the facility with IV PICC line that required 24h nursing assistance posed an immediate Health [..] risk to persons in care.
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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: 12/08/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/08/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/08/2025 05:07 PM - It Cannot Be Edited


Created By: Perchui Khurshudyan On 12/08/2025 at 04:44 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: WOODLAKE LOVING CARE LLC
FACILITY NUMBER: 197609495

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/08/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/19/2025
Section Cited
CCR
87616(a)

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(a) As specified in Section 87209, Program Flexibility, the licensee may submit a written exception request agrees that the resident has a prohibited and/or restrictive health condition but believes that the intent of the law can be met through alternative means. This requirement was not met as evidenced by
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The resident is no longer receiving IV PICC line therapy.Licensee/administrators and all staff will need to attend 2 hours vendorized traiing related to acceptance retention limitation, prohibited health condition and exception requests.
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Based on records reviewed and interview held with Administrator which revealed that R1 was re-admitted to the facility prior to submitting and received an exception request approval, which posed a potential health and safety and personal rights risk to residents in care.
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Verification os scheduled training will need to be submitted 12/9/25 and proof of completion will need to be at a later time.

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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: 12/08/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/08/2025


LIC809 (FAS) - (06/04)
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