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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609782
Report Date: 03/17/2026
Date Signed: 03/17/2026 12:07:38 PM

Document Has Been Signed on 03/17/2026 12:07 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 N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:CARRIES CARE VILLAFACILITY NUMBER:
197609782
ADMINISTRATOR/
DIRECTOR:		ACOSTA, MARK RYANFACILITY TYPE:
740
ADDRESS:12550 BURTON STTELEPHONE:
(818) 767-4503
CITY:NORTH HOLLYWOODSTATE: CAZIP CODE:
91605
CAPACITY: 6CENSUS: 5DATE:
03/17/2026
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:57 AM
MET WITH:Carrie AcostaTIME VISIT/
INSPECTION COMPLETED:
12:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Trevor Byrne and Long-Term Care Ombudsman Diane Torres arrived to the facility at 09:57 AM to conduct an unannounced Case Management - Deficiencies visit at the facility today. LPA met with facility staff who contacted the Administrator Carrie Acosta. The Administrator arrived to the facility at approximately 10:50 AM. Entrance interview was conducted and the reason for the visit was explained.

The purpose of today’s visit was to follow-up on a self-reported incident that occurred on 02/18/2026. During today’s visit, the LPA and LTCO conducted a physical plant tour, conducted a file review for one (1) resident, interviewed three (3) residents, and interviewed the Administrator between 10:02 AM and 12:00 PM.

On 03/12/2026 Community Care Licensing Division (CCLD) received a self-reported incident report regarding an incident that occurred on 02/18/2026. LPA interviewed the Administrator and asked why the reports were not submitted to CCLD in a timely manner. Administrator explained that they waited to submit the incident report because they were waiting to see if the resident would be returning to the facility. LPA informed Administrator that a written report shall be submitted to the licensing agency and to the person responsible for the resident within seven (7) days of the occurrence any incident which threatens the welfare, safety or health of any resident. Administrator confirmed that they are aware of the reporting requirement and agreed to submit a written statement confirming that they will submit all future incident reports to CCLD within the required timeframe.

CONTINUED ON LIC 809C.

NAME OF LICENSING PROGRAM MANAGER: Kasandra Lopez
NAME OF LICENSING PROGRAM ANALYST: Trevor Byrne
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 03/17/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/17/2026
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 N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: CARRIES CARE VILLA
FACILITY NUMBER: 197609782
VISIT DATE: 03/17/2026
NARRATIVE
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During the physical plant tour LPA and LTCO observed the staff bedroom of the facility to be unlocked. LPA and LTCO observed unsecured cleaning supplies in the staff bedroom including a bottle of floor cleaning chemicals. LPA informed the Administrator 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. The Administrator expressed understanding and secured the chemicals at the time off the visit.

Pursuant to Title 22, California Code of Regulations, the following deficiencies were cited (refer to LIC 809-D.) Exit interview conducted and copy of the report and appeal rights were issued.

NAME OF LICENSING PROGRAM MANAGER: Kasandra Lopez
NAME OF LICENSING PROGRAM ANALYST: Trevor Byrne
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/17/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/17/2026
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/17/2026 12:07 PM - It Cannot Be Edited


Created By: Trevor Byrne On 03/17/2026 at 11:34 AM
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. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: CARRIES CARE VILLA
FACILITY NUMBER: 197609782

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/17/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/18/2026
Section Cited
CCR
87309(a)

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87309 Storage Space and Access
(a) ... the licensee shall ensure that disinfectants, cleaning solutions...are in locked storage and are not left unattended if outside the locked storage.
This requirement is not met as evidenced by:
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Licensee locked the staff room and secured the cleaning supplies at the time of the visit. Licensee agreed to conduct a training with staff on the importance of securing cleaning chemicals. Licensee agreed to submit proof of completed training to CCLD no later than POC due date.
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Based on observation the licensee did not comply with the section cited above as the staff room was observed to be unlocked and contained unsecured cleaning supplies which posed an immediate safety risk to clients in care.
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Type B
03/31/2026
Section Cited
CCR87211(a)(1)(D)

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87211 Reporting Requirements
(a) Each licensee shall furnish...:
(1) A written report shall be submitted to... licensing...within seven days of...
(D) Any incident which threatens the welfare, safety or health of any resident...
This requirement is not met as evidenced by:
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Administrator agreed to submit a statement of understanding confirming that they will adhere to the required timeframe when reporting incidents to CCLD. Administrator agreed to submit the document to CCLD no later than POC due date.
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Based on record review and interview the licensee did not comply with the section cited above as an incident report was not submitted to licensing within the required timeframe which posed a potential health, safety, or personal rights risk to clients 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.
Kasandra Lopez
NAME OF LICENSING PROGRAM MANAGER:
Trevor Byrne
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 03/17/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/17/2026


LIC809 (FAS) - (06/04)
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