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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609791
Report Date: 07/17/2025
Date Signed: 07/22/2025 09:19:07 AM

Document Has Been Signed on 07/22/2025 09:19 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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:ATWATER VILLAGE SOUTHFACILITY NUMBER:
197609791
ADMINISTRATOR/
DIRECTOR:		ESPIRITU, JOCELYNFACILITY TYPE:
740
ADDRESS:3454 PERLITA AVETELEPHONE:
(323) 665-6893
CITY:LOS ANGELESSTATE: CAZIP CODE:
90039
CAPACITY: 6CENSUS: 6DATE:
07/17/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:45 AM
MET WITH:Jocelyn EspirituTIME VISIT/
INSPECTION COMPLETED:
02:45 PM
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On Thursday, 07/17/25, 9:45 am, Licensing Program Analyst, (LPA) Raymond Comer, arrived to conduct an unannounced annual inspection visit. LPA met with Administrator Jocelyn Espiritu, and reason for the visit was discussed. Facility is licensed as a single-story residence. Total capacity for six (6) non-ambulatory; one may be bedridden. Hospice waiver for four (4). Facility has four (4) total resident bedrooms; two private, and two shared. Facility has two (2) bathrooms.

At 10:00 am, LPA conducted a tour of the physical plant with the Administrator and observed the following:

PHYSICAL PLANT was inspected for cleanliness and condition. Facility’s main door is the primary entry/exit access. Screening area is located immediately upon entrance. Visitor Sign-in sheet, hand sanitizer, gloves and masks are available. Hand washing, coughing etiquette, and other necessary signage are posted throughout the facility. Room temperature is comfortable; wall thermostat displays a setting of 76.0°F., within the required range. Rear glass doors allow exiting to back yard. The facility maintains a Mitigation and Infection Control plan. Required postings are prominently displayed and observed to be current. Disaster drills were last conducted on 7/01/2025.


[LIC 809C]-Continued
NAME OF LICENSING PROGRAM MANAGER: Eva Miller
NAME OF LICENSING PROGRAM ANALYST: Raymond Comer
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/17/2025
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: ATWATER VILLAGE SOUTH
FACILITY NUMBER: 197609791
VISIT DATE: 07/17/2025
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KITCHEN area is clean and clear of clutter. LPA observed refrigerator, microwave, stove/oven, dishwasher and sink to be operational. Knives/Sharps are stored in lower cabinets, locked and inaccessible to residents. Plates, cups, utensils, and two day supply of perishable food is properly stored and labeled. A seven day supply of nonperishable food is located in kitchen area pantry. Dish Soap, cleaning solutions, and toxins are stored in locked lower cabinet underneath the kitchen sink.

FIRE DETECTION/SUPPRESSION SYSTEM present at facility. Multiple combination smoke\ carbon monoxide alarm detectors are installed, hardwired and interconnected. Smoke and Carbon monoxide detectors were tested and function properly. Two (2) fire extinguishers were observed; located near the front entrance and rear exit. Extinguishers indicate a full charge; last inspection service date: 03/11/2025.

BEDROOMS: Resident bedrooms #2 and #3 are private. Resident bedrooms #1 and #4 are shared. All bedrooms are observed as clean with sufficient lighting, properly furnished with bedding, linens, at least one chair, and night stand.

BATHROOMS were observed to be clean and sanitary with necessary supplies and required safety fixtures (grab bars, anti-slip floor stripping). Hot water temperature measured at 117°F. Within the required range.

OUTDOORS: (backyard) area observed to have a shaded patio, with tables with sufficient seating for the residents. Patio furniture was observed to be in good condition. All trash cans were observed to be covered. There are no bodies of water in the facility.

COMMON AREAS: Entry and exit doors have a functional auditory alert when the doors open. Dining room is furnished with table large enough to accommodate residents, staff, and visitors. Dining room furnishing with sitting area, television, stored games, reading materials. Furniture and fixtures are clean and in good condition. Facility telephone was operational at time of visit.



RESIDENT RECORDS are stored in secure and locked file cabinet in kitchen area and inaccessible to residents. Records were reviewed for current IPP and/or Needs and Services plans, physician report, and admission agreements. Resident records appear to be complete and current.


[LIC 809C]-Continued
NAME OF LICENSING PROGRAM MANAGER: Eva Miller
NAME OF LICENSING PROGRAM ANALYST: Raymond Comer
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2025
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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: ATWATER VILLAGE SOUTH
FACILITY NUMBER: 197609791
VISIT DATE: 07/17/2025
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STAFF RECORDS are stored in secure and locked file cabinet in kitchen area and are inaccessible to residents. Records were checked for criminal record clearances\associations to this facility. Staff records appear to be complete and current.

MEDICATIONS: are stored in locked and secured medications cart located in the kitchen area; inaccessible to residents. Medications are listed on a centrally stored medication and destruction record log. A First Aid kit is complete.

No immediate health and safety hazards observed during today's inspection.

Exit interview conducted and a copy of this report was given.
NAME OF LICENSING PROGRAM MANAGER: Eva Miller
NAME OF LICENSING PROGRAM ANALYST: Raymond Comer
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2025
LIC809 (FAS) - (06/04)
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