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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609534
Report Date: 07/08/2025
Date Signed: 07/08/2025 11:25:09 AM

Document Has Been Signed on 07/08/2025 11:25 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
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:AZALEA GARDENSFACILITY NUMBER:
197609534
ADMINISTRATOR/
DIRECTOR:		ABDELKADER,FOOREVER C.FACILITY TYPE:
740
ADDRESS:6231 AZALEA DRIVETELEPHONE:
(661) 422-6160
CITY:QUARTZ HILLSTATE: CAZIP CODE:
93536
CAPACITY: 6CENSUS: 2DATE:
07/08/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:50 AM
MET WITH:Khristine Campbell - Administrator DesigneeTIME VISIT/
INSPECTION COMPLETED:
11:35 PM
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Licensing Program Analyst (LPA) Evelin Rios conducted an unannounced annual visit at this facility. LPA was greeted and granted access by staff #1 (S1). The administrator designee, Khristine Campbell met with LPA shortly after and LPA explained the purpose of the visit. The facility has an approved fire clearance for five (5) non-ambulatory and one (1) bedridden resident in Room #5 for a total capacity of 6. The facility has a Hospice waiver for two (2) residents.

A tour of the physical plant inside and out was conducted at 9:15 a.m., and the following was observed: At entry LPA observed a screening area where visitors can sign in, hand sanitizer, and face masks available. LPA observed appropriate postings on a wall by the front entrance.

Kitchen: LPA conducted a tour of the kitchen and observed there to be sufficient supply of two day perishables and seven day non-perishables foods, properly stored. Food storage and preparation areas are clean and clear of clutter. LPA observed all knives, sharp object, locked in a kitchen drawer inaccessible to residents in care. There is one (1) fire extinguisher located in the kitchen was fully charged with purchase date 02/12/2025. A first aid kit with an up-to-date manual was observed in a kitchen drawer. Centrally stored medications are maintained locked in a kitchen cabinet. There are cordless telephones available to residents.

Common areas: LPA observed the living area, breakfast nook and formal dining area to be clean and clear of clutter. The furniture was in good repair and sits the capacity of the facility. In the breakfast nook LPA observed games and hand therapy tools to assist residents with dexterity.
(Continue to LIC809-C)
NAME OF LICENSING PROGRAM MANAGER: Eva Miller
NAME OF LICENSING PROGRAM ANALYST: Evelin Rios
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/08/2025
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 3
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
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: AZALEA GARDENS
FACILITY NUMBER: 197609534
VISIT DATE: 07/08/2025
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(Continued from LIC809) Surrounding Grounds: Entry and exits were free of obstructions. There is a covered patio with appropriate furniture. There are no bodies of water and the backyard is fenced in.

Laundry and Garage: Laundry room was observed locked. Detergents and cleaning supplies are kept locked in the laundry room. The garage can be accessed through the laundry room.

Bedrooms: There are five (5) resident bedrooms. Four (4) out of five (5) bedrooms are for private use. LPA observed each resident room to be properly furnished with beds, appropriate night stand, chair, bedding and have sufficient lighting and storage.

LPA observed the administrator designee test a dual smoke and carbon monoxide detector at 9:24 a.m. Detectors are interconnected to other detectors located through out the facility. LPA observed detectors functioning properly. LPA observed fire doors close when smoke detectors were tested.

Bathrooms: The facility has three (3) bathrooms. One (1) is located in a resident's private bedroom. Bathrooms were clean and properly supplied with hand soap, toilet paper, and paper towels. LPA observed non skid shower mats and proper grab bars by showers and toilets. LPA observe night lights leading to hallway bathroom by bedrooms. Facility has a linen closet that stores extra bedding, towels and hygiene products. LPA observed a second closet with emergency food, water and supplies for a disaster.

Resident/Staff/Facility Records: At 9:57 a.m., LPA reviewed two (2) of two (2) resident records to insure compliance with licensing forms. At 10:14 a.m., medications and Centrally Stored Medication and Destruction Records were reviewed for proper documentation. Medication records are maintained manually and facility keeps Medication Administration Records (MAR) as well. At 10:18 a.m, LPA reviewed two (02) staff records to insure compliance with licensing forms. LPA reviewed facility's Liability Insurance Policy, LIC 500, emergency disaster training for fire drill conducted on 05/2025, and infection control plan reviewed 05/2025.

Pursuant to Title 22 Division 6 of the CA Code of Regulations, there were no deficiencies observed during todays visit. Exit Interview Conducted. A copy of this report provided.
NAME OF LICENSING PROGRAM MANAGER: Eva Miller
NAME OF LICENSING PROGRAM ANALYST: Evelin Rios
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2025
LIC809 (FAS) - (06/04)
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