<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609594
Report Date: 03/28/2026
Date Signed: 03/28/2026 02:56:11 PM

Document Has Been Signed on 03/28/2026 02:56 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.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:SPARR HEIGHTS ESTATES SENIOR LIVINGFACILITY NUMBER:
197609594
ADMINISTRATOR/
DIRECTOR:		LEWIS, ERNESTFACILITY TYPE:
740
ADDRESS:2640 HONOLULU AVETELEPHONE:
(818) 248-6737
CITY:MONTROSESTATE: CAZIP CODE:
91020
CAPACITY: 131CENSUS: 75DATE:
03/28/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:48 AM
MET WITH:Denise Gotto - Executive DirectrorTIME VISIT/
INSPECTION COMPLETED:
03:00 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Jose Tan initially met with the receptionist Bertha Barbes who called the Executive Director and explained the reason for the visit. Ms. Gotto stated that the files were locked so she would be at the facility. Ms. Gotto arrived at around 11:16 AM.

A tour of the physical plant was conducted at around 10:41 AM with the Marketing Director and eventually the Executive Director and the following was noted:

The facility is fire cleared for one hundred twenty (120) non-ambulatory of which twenty (20) may be bedridden. The facility is currently occupying a total of seventy-five (75) residents, ten (10) of which are in hospice care.

There is only one main entrance being utilized at the facility with sign-in sheets. Each residents' room has a full bathroom. LPA inspected random rooms in Memory Care and Assisted Living both first and second floor. Room 3E of Memory Care has toxins under the sink and Room 7E of Memory Care has no hot water on its sink. All rooms were observed to be adequately furnished with appropriate lighting system and enough clean linen available. Hallways are well lit. Residents have enough personal hygiene products provided by the licensee. The bathroom was checked for cleanliness and proper operation. The hot water temperature was measured at a range of 108.9°F to 118.9°F. Towels and washcloths are not shared.

The facility has outdoor furniture with a covered shaded area for residents and visitors. The facility does not have a swimming pool/body of water. Laundry detergents, cleaning agents and other toxins were observed to be locked in the parking area. (continued on LIC 809-C)

NAME OF LICENSING PROGRAM MANAGER: Troy Agard
NAME OF LICENSING PROGRAM ANALYST: Jose Gary Tan
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 03/28/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/28/2026
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)
Page: 2 of 5
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: SPARR HEIGHTS ESTATES SENIOR LIVING
FACILITY NUMBER: 197609594
VISIT DATE: 03/28/2026
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
(continued from 809)

Kitchen is sufficiently stocked with at least two (2) days perishable and seven (7) days non-perishable food. Frozen foods are wrapped and stored appropriately. Food storage and preparation areas are clean and inaccessible to pests. Knives and sharps are observed to be locked and inaccessible to residents.

The facility has two (2) elevators, both of which are working properly. The facility maintains a comfortable temperature at 75°F. The facility's smoke alarms are hard-wired, interconnected with a pull system. The facility is equipped with sprinkler system but the facility has been currently on fire watch since September 2025, and per the Executive Director, they are in the process of updating their fire alarm and pull system. Fire extinguishers are located all throughout the facility and were last serviced on 02/11/26. Fire Drill was last conducted on 03/26/26.

The living, dining and activity rooms are neat and clean. The facility maintains a comfortable temperature at 73°F but each resident has their own thermostat and can control the temperature in their rooms. The smoke alarms are hardwired, interconnected and centralized. Each room has a carbon monoxide detector installed. A signal is dispatched to the Los Angeles Fire Department automatically and the system is tested monthly. Laundry area is located in the basement area and is inaccessible to residents. Emergency drinking waters are also located in the basement/parking area.



Medications were observed to be locked in the medication carts and inaccessible to residents. There were two (2) complete first aid kits in the medication room and medication carts. LPA observed medication carts locked and inaccessible to residents. Facility maintains a complete first aid kit.

At 2:20 PM, LPA reviewed records of six (6) random residents and six (6) staff. Residents' records are observed to be current and updated. Staff #1 (S1) did not have a First Aid certificate on file.

Citation issued. Appeal rights discussed and given.



Exit interview conducted. Copy of this report issued.
NAME OF LICENSING PROGRAM MANAGER: Troy Agard
NAME OF LICENSING PROGRAM ANALYST: Jose Gary Tan
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/28/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2026
LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 03/28/2026 02:56 PM - It Cannot Be Edited


Created By: Jose Gary Tan On 03/28/2026 at 02:14 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: SPARR HEIGHTS ESTATES SENIOR LIVING
FACILITY NUMBER: 197609594

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/28/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space and Access
(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above as toxins were observed to be unlocked in the sink of Memory Care dining room and Room 3E, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/28/2026
Plan of Correction
1
2
3
4
Cleared during visit. ED removed all the toxins and kept it in a locked storage room.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Troy Agard
NAME OF LICENSING PROGRAM MANAGER:
Jose Gary Tan
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 03/28/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/28/2026


LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 03/28/2026 02:56 PM - It Cannot Be Edited


Created By: Jose Gary Tan On 03/28/2026 at 02:15 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: SPARR HEIGHTS ESTATES SENIOR LIVING
FACILITY NUMBER: 197609594

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/28/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation], the licensee did not comply with the section cited above as Room 7E of the Memory Care unit did not have hot water in the sink, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/08/2026
Plan of Correction
1
2
3
4
The Executive Director agreed to immediately create a work order to repair the faucet in Room 7E and will submit proof of repair to LPA on or before the POC date.
Type B
Section Cited
CCR
87411(c)(1)
Personnel Requirements - General
(1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in 1 out of 6 staff records reviewed did not have first aid certificate on file, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/08/2026
Plan of Correction
1
2
3
4
ED agreed to obtain the First Aid certificate of S1 and will submit a copy to LPA on or before the POC date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Troy Agard
NAME OF LICENSING PROGRAM MANAGER:
Jose Gary Tan
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 03/28/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/28/2026


LIC809 (FAS) - (06/04)
Page: 5 of 5