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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609767
Report Date: 08/14/2025
Date Signed: 08/14/2025 03:10:07 PM

Document Has Been Signed on 08/14/2025 03:10 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
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:ASSURE CARE VILLAFACILITY NUMBER:
197609767
ADMINISTRATOR/
DIRECTOR:		PEREGRINO, FLORENCEFACILITY TYPE:
740
ADDRESS:8854 OAKDALE AVETELEPHONE:
(747) 237-2345
CITY:NORTHRIDGESTATE: CAZIP CODE:
91324
CAPACITY: 6CENSUS: 5DATE:
08/14/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:43 AM
MET WITH:Dennis BonifacioTIME VISIT/
INSPECTION COMPLETED:
03:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Mariana Agban conducted an Annual Required visit and inspection of the facility. LPA met with staff Dennis Bonifacio, and explained the reason for the visit. LPA was informed that Florence Peregrino is no longer administrator of the facility as there was a change within the organization since January of 2025. LPA was given the contact information of Susan Nuguid, the new Administrator and was informed that Mrs. Nuguid is out of the country. Administrator Nuguid had assigned staff Dennis to Bonifaco to sign the report. At approximately 11:15 am, with the assistance of staff, LPA took a tour of the physical plant. Required postings were observed in the entry area.

Kitchen: The kitchen appliances and fixtures were functional. LPA found a sufficient amount of perishable and non-perishable food at the facility; properly stored. Knives were stored in a locked drawer in the kitchen. Properly labeled medications were locked in one of the kitchen cabinets. The laundry area is located through the kitchen. The washer and dryer were observed to be in good condition. No toxins or other hazards items were present.
Bedrooms: There were five (5) bedrooms designated for residents' use. Four (4) bedrooms are designated for private use, and one (1) room is shared. All five bedrooms, in use by residents, were properly furnished with appropriate beddings and linens with sufficient lighting. Currently, Room 4 is vacant. LPA was informed that R1 had passed away on or around June 13, 25. LPA conducted a file review and did not observe any death report had been sent out to CCL regarding R1's death.
Bathrooms: There were four (4) bathrooms in the facility. One (1) bathroom in hallway and three (3) bathrooms in the private bedrooms. All bathrooms were clean, properly supplied and had functional fixtures. Hot water temperature was 110.6 degrees Fahrenheit. Cleaning supplies were kept in locked cabinets. Temperature: Facility maintains a comfortable temperature of 77 degrees Fahrenheit.
(Continue on 809C)
NAME OF LICENSING PROGRAM MANAGER: Eva Miller
NAME OF LICENSING PROGRAM ANALYST: Mariana Agban
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 08/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/14/2025
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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Document Has Been Signed on 08/14/2025 03:10 PM - It Cannot Be Edited


Created By: Mariana Agban On 08/14/2025 at 12:31 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: ASSURE CARE VILLA
FACILITY NUMBER: 197609767

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/14/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87211(g)(1)(2)(3)
(g)The licensee shall notify the Department, in writing, within thirty (30) days of the hiring of a new administrator. The notification shall include the following:(1) Name and residence and mailing addresses of the new administrator.
(2) Date he/she assumed his/her position. (3) Description of his/her background and qualifications, including documentation of required education and administrator certification. This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above. The Licensee hired new Administrator on or around March without notfity CCL within 30 days which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/28/2025
Plan of Correction
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Licensee will provide a copy of the entire employee file for the new Administrator by the POC date
Type B
Section Cited
CCR
87211(h)


Any change in the chief corporate officer of an organization, corporation or association shall be reported to the licensing agency in writing within fifteen (15) working days following such change. Such notification shall include the name, address, and the fingerprint card of the new chief executive officer, as required by Section 87355, Criminal Record Clearance. This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview, the licensee did not comply with the section cited above. LPA was informed that there was an organization change within the cooperation since January of 2025 and the licensee did not notify CCL within 15 days reagrding the change which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/28/2025
Plan of Correction
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Licensee will submit to CCL notification with the changes happened within the organization by 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.
Eva Miller
NAME OF LICENSING PROGRAM MANAGER:
Mariana Agban
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/14/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/14/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/14/2025 03:10 PM - It Cannot Be Edited


Created By: Mariana Agban On 08/14/2025 at 01:45 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: ASSURE CARE VILLA
FACILITY NUMBER: 197609767

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/14/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87405(a)


87405(a) When the administrator is not in the facility,there shall be coverage by a designated substitute who shall have qualifications adequate to be responsible and accountable for management and administration of the facility as specified in this section.This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the licensee did not comply with the section cited above. There's no administrator designee present at the facility which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/28/2025
Plan of Correction
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Licensee will complete the Designation of Facility Responsibility (LIC 308) and will email the form by the POC date.
Type B
Section Cited
CCR
80061(b)
Reporting Requirements. Upon the occurrence…a report shall be made to the licensing agency..., a written report ...within seven days following the occurrence of such event.
This requirement was not met as evidence by:

Deficient Practice Statement
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 Based on file document review, the Licensee did not comply with the section cited above. Licensee didn't submit a death report for R1 since R1 passed away on or around of June 13, 2025. This poses a potential health and safety risk to clients in care.
POC Due Date: 08/28/2025
Plan of Correction
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Licensee will submit death report for R1 to CCL by 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.
Eva Miller
NAME OF LICENSING PROGRAM MANAGER:
Mariana Agban
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/14/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/14/2025


LIC809 (FAS) - (06/04)
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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: ASSURE CARE VILLA
FACILITY NUMBER: 197609767
VISIT DATE: 08/14/2025
NARRATIVE
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Smoke Alarms and Carbon Monoxide: detectors were tested and function properly. Fire extinguisher is located in the kitchen with purchase date 11/4/24. Common Areas: These included the living room and dining area. The common areas were properly furnished with adequate couches, chair, and television. The dining area had a large table, to seat up to six (6) individuals. Furniture in common areas were clean and in good repair. Floors were mopped and clean. Hallways and passageways were clear of any obstruction. Surrounding Grounds: Entry/exits were free of obstruction. LPA observed the outdoor area to be cluttered with unused bedframes, broken exercise machines and outdoor furniture. No lock on the side gate. Resident Files: LPA conducted a file review of two out of 5 residents records to ensure compliance of licensing forms. LPA observed that R2 and R3 Appraisal Needs and Services (LIC 625) are not updated. Staff Files: LPA was unable to conduct staff file review for S1 as there was no physical file for S1. LPA conducted file review for 2 out 2 present staff. LPA requested copy of the liability insurance. LPA was informed that there are no physical copy of the liability insurance on file. LPA was unable to complete the annual inspection during today's visit. The administrator was informed that a follow-up visit will be conducted.

Exit interview conducted. Citations issued, appeal rights given, Copy of report provided.
NAME OF LICENSING PROGRAM MANAGER: Eva Miller
NAME OF LICENSING PROGRAM ANALYST: Mariana Agban
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2025
LIC809 (FAS) - (06/04)
Page: 5 of 7
Document Has Been Signed on 08/14/2025 03:10 PM - It Cannot Be Edited


Created By: Mariana Agban On 08/14/2025 at 02:25 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: ASSURE CARE VILLA
FACILITY NUMBER: 197609767

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/14/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.618(b)
Other Provisions
(b) At least one administrator, facility manager, or designated substitute who is at least 21 years of age and has qualifications adequate to be responsible and accountable for the management and administration of the facility pursuant to Title 22 of the California Code of Regulations shall be on the premises 24 hours per day. The designated substitute may be a direct care staff member who shall not be required to meet the educational, certification, or training requirements of an administrator. The designated substitute shall meet qualifications that include, but are not limited to, all of the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the licensee did not comply with the section cited above. The facility does not have a designated substitute which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/28/2025
Plan of Correction
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Licensee will hire a designated substitute and will update LIC 500 and email the form to LPA by the POC date.
Type B
Section Cited
HSC
1569.605
Other Provisions
On and after July 1, 2015, all residential care facilities for the elderly, except those facilities that are an integral part of a continuing care retirement community, shall maintain liability insurance covering injury to residents and guests in the amount of at least one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate, caused by the negligent acts or omissions to act of, or neglect by, the licensee or its employees.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the licensee did not comply with the section cited above. Licensee did not have a copy of the facility liability insurance which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/28/2025
Plan of Correction
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Licensee will email a copy of the facility's insurance to LPA by 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.
Eva Miller
NAME OF LICENSING PROGRAM MANAGER:
Mariana Agban
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/14/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/14/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/14/2025 03:10 PM - It Cannot Be Edited


Created By: Mariana Agban On 08/14/2025 at 02:25 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: ASSURE CARE VILLA
FACILITY NUMBER: 197609767

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/14/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87219(h)
Planned Activities
(h) The licensee shall provide sufficient space to accommodate both indoor and outdoor activities. Activities shall be encouraged by provision of:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. Outdoor area is cluttered and outdoor furniture are broken which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/28/2025
Plan of Correction
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Licensee will provide a picture of cleaned outdoor area and new outdoor furniture purchased.
Type B
Section Cited
CCR
87463(a)
Reappraisals
(a) The pre-admission appraisal, as specified in Section 87457, Pre-Admission Appraisal, shall be updated, in writing as frequently as necessary or once every 12 months, whichever occurs first, to note significant changes in condition, as defined in Section 87101, Definitions, and to keep the appraisal accurate. For the purposes of this section, the updated pre-admission appraisal shall be referred to as the reappraisal.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above. R1 and R3 don't have updated Appraisal Needs and Services (LIC 625) which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/28/2025
Plan of Correction
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Licensee will email updated Appraisal Needs and Services (LIC 625) for R1 and R3 to LPA by 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.
Eva Miller
NAME OF LICENSING PROGRAM MANAGER:
Mariana Agban
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/14/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/14/2025


LIC809 (FAS) - (06/04)
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