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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609667
Report Date: 09/19/2025
Date Signed: 09/19/2025 04:02:10 PM

Document Has Been Signed on 09/19/2025 04:02 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:AAA'S ELDERLY CARE INCFACILITY NUMBER:
197609667
ADMINISTRATOR/
DIRECTOR:		REYES, MARICELFACILITY TYPE:
740
ADDRESS:3960 WOBURN CTTELEPHONE:
(661) 350-2232
CITY:PALMDALESTATE: CAZIP CODE:
93551
CAPACITY: 6CENSUS: 5DATE:
09/19/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Adrian ReyesTIME VISIT/
INSPECTION COMPLETED:
01:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Melissa Spaeth conducted an unannounced visit on 9/19/2025 and was greeted by staff members Salik Charley and Mary Martin. LPA stated the purpose of the visit was to conduct an annual inspection. The staff confirmed there are five residents. The facility is licensed for six (6) non-ambulatory, bedridden residents. The Licensee Adrian Reyes arrived at 10:10 am

LPA Spaeth and the caregiver toured the facility at 10:00 am until 10:30 am

Common Areas – The living room and family room contained comfortable seating. A dining room table with chairs are located in the kitchen. The family room contained a television.

Kitchen - LPA Spaeth observed a two day supply of perishable food and a seven day supply of non-perishable foods. The knives and cleaning solutions were locked in a cabinet. The fire extinguisher is located in the kitchen and is operable.

Medication - LPA observed the resident medications and PPE supplies were safely locked in a kitchen cabinet. LPA observed the first aid kit.

Resident Rooms: The resident rooms were furnished with a bed, linens, night stand, lamp and chair. The rooms were neat and clean.

Continued 809-C

NAME OF LICENSING PROGRAM MANAGER: Troy Agard
NAME OF LICENSING PROGRAM ANALYST: Melissa Spaeth
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/19/2025
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 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)
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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: AAA'S ELDERLY CARE INC
FACILITY NUMBER: 197609667
VISIT DATE: 09/19/2025
NARRATIVE
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Garage//Washer & Dryer – The laundry room contained the washer/dryer. The door leading to the garage was locked. Additional cleaning supplies and the laundry detergent were not securely locked. An additional refrigerator is located in the garage and contained additional food items.

Staff Room: The staff room was not locked but there were no safety issues to report.

Bathrooms: There are two (2) bathrooms in the facility. The bathrooms contained hand soap, paper towels, grab bars, and trash can. A slip resistant mat was missing in one of the bathrooms. LPA observed cleaning supplies were not safely locked in a cabinet. LPA observed the staff member removed the cleaning supplies and locked in a cabinet. At 11:15 am, a slip resistant mat was placed in the bathroom.

Water Temperature: The water temperature was tested at 10:15 am and was 110 degrees F.

Hallway Closet - LPA observed the clean linens were located in a cabinet.

Surrounding Grounds: LPA observed the gate to the wooden fence on the side of the facility was broken. The Licensee confirmed the gate will be repaired.

Smoke/Carbon Monoxide Detectors: The smoke and carbon monoxide detectors were tested at 10:20 am and were operable.

LPA Spaeth reviewed the resident and staff files from 11:10 am until 12:15 pm. There were no issues with the resident and staff files.

Based upon Title 22 Regulations, the following deficiencies are substantiated. (See 809-D page).

Exit interview conducted, appeal rights discussed, and a copy of the signed report was given

NAME OF LICENSING PROGRAM MANAGER: Troy Agard
NAME OF LICENSING PROGRAM ANALYST: Melissa Spaeth
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2025
LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 09/19/2025 04:02 PM - It Cannot Be Edited


Created By: Melissa Spaeth On 09/19/2025 at 12:09 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: AAA'S ELDERLY CARE INC
FACILITY NUMBER: 197609667

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/19/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(e)(5)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (5) Slip-resistant mats, strips, or flooring shall be used in all bathtub and shower floors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observation, the licensee did not comply with the section cited above. LPA observed a slip resistant mat was missing from the resident bathroom which could possibly pose a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/19/2025
Plan of Correction
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During LPA's visit, LPA observed a slip resistant mat was placed in the shower area in the bathroom.
Type B
Section Cited
CCR
87303(a)
87303 Maintenance & Operation (a) The facility shall be clean, safe and in good repair at all times….

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observation, the licensee did not comply with the section cited above. LPA observed the wooden gate in the backyard was broken which could possibly pose a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/26/2025
Plan of Correction
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The Licensee will send a snapshot of the repaired wooden gate to LPA Spaeth
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:
Melissa Spaeth
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/19/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/19/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/19/2025 04:02 PM - It Cannot Be Edited


Created By: Melissa Spaeth On 09/19/2025 at 12:23 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: AAA'S ELDERLY CARE INC
FACILITY NUMBER: 197609667

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/19/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87309(a)
87309 Storage Space & Access (a)…The licensee shall ensure that disinfectants, cleaning solutions…are in locked storage…

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observation, the licensee did not comply with the section cited above. LPA observed cleaning solutions in the master bathroom were no locked in a secure cabinet, which could possibly pose a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/19/2025
Plan of Correction
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LPA observed the staff member safely locked the cleaning solutions in a locked cabinet.
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.
Troy Agard
NAME OF LICENSING PROGRAM MANAGER:
Melissa Spaeth
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/19/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/19/2025


LIC809 (FAS) - (06/04)
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