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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609947
Report Date: 10/07/2025
Date Signed: 10/07/2025 02:19:55 PM

Document Has Been Signed on 10/07/2025 02:19 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.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:PRIMROSE 3FACILITY NUMBER:
197609947
ADMINISTRATOR/
DIRECTOR:		NAIMUDDIN, MUBEENFACILITY TYPE:
740
ADDRESS:17537 BLYTHE STREETTELEPHONE:
(323) 872-2755
CITY:NORTHRIDGESTATE: CAZIP CODE:
91325
CAPACITY: 6CENSUS: 6DATE:
10/07/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:15 AM
MET WITH:Christopher Rogue de Guzman, CaregiverTIME VISIT/
INSPECTION COMPLETED:
02:30 PM
NARRATIVE
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On 10/07/25, at 8:15am., Licensing Program Analyst (LPA) Gina Saucedo arrived at the facility to conduct an unannounced, annual visit. Upon arrival, LPA met with Caregiver, Christopher Rogue de Guzman and disclosed the purpose of the visit. The administrator was called and stated they were out of town.

LPA asked for the census, resident, and staff rosters.

The facility tour started 8:55am Temperature of facility wall thermostat is observed and set to 76 degrees Fahrenheit.

Medications-LPA observed medication stored in one (1) of the lower cabinets locked and secured in the kitchen area inaccessible to residents.

Kitchen area was sufficiently stocked with seven (7) days of perishable and seven (7) days of non-perishable food. Sharps/Knives are stored and locked in one (1) of the cabinets in the kitchen on the right side of the sink. Toxins are kept secured and locked in one (1) of the cabinets under the kitchen sink inaccessible to residents. There is one (1) fire extinguisher located against the wall in the kitchen area on your left hand side fully charged and dated August 2025.



There is a backyard which has outdoor furniture and grassy area for outdoor activities. There is no pool/and or bodies of water.

LIC 809C-continued

NAME OF LICENSING PROGRAM MANAGER: Troy Agard
NAME OF LICENSING PROGRAM ANALYST: Gina Saucedo
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 10/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/07/2025
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 10
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 10
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: PRIMROSE 3
FACILITY NUMBER: 197609947
VISIT DATE: 10/07/2025
NARRATIVE
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The garage is attached to the house and was observed to be locked and used to store toxins, extra storage. There is a washer and dryer located in this area. There is also one (1) refrigerator in the garage with extra food.

Bedrooms/Bathrooms: There is five (5) bedrooms. One (1) bedroom is shared, three (3) bedrooms are single occupied. All five (5) bedrooms are properly furnished with proper lightning. The bathrooms have proper toiletry and grab bars. There is one (1) bathroom that is located by the entrance of the facility that is used by staff and residents. There are two (2) bedrooms that have private bathrooms. The bathroom temperature of the water are within regulations. It reads between 112.5-119 Degree Fahrenheit.

Living and dining room furniture is accessible for six (6) residents and staff. There is a television, telephone line and enough seating for residents and staff. Furniture was observed to be in good condition and there is no fireplace.

The smoke/carbon monoxide detectors are hardwired and interconnected and were tested. They were functional.

Administrative: The Insurance plan is updated and expires on 07/2026, disaster plan, administrator certificate, Designation of facility responsibility, Admission Agreement, Personal Rights, resident rights signs are against the wall at the entrance of the facility, Infection Control and Disaster Plan, Ombudsman.



Staff/Resident Files Reviewed: Six (6) resident files were reviewed and three (3) staff files were reviewed. Five (5) out of six (6) residents are missing functional capabilities form, five (5) out of six residents are missing resident appraisal form, One (1) resident is missing physician's report and tuberculosis, One (1) resident out of six (6) resident is missing pre-placement form, three (3) out of six (6) residents are missing needs and services plan. There are two (2) staff that are missing several forms such as Criminal Background/Fingerprinting, Personnel Record and education, training to provide medication to residents.


An exit interview was conducted, several citation(s) were issued, appeals rights and a copy of this report was given to the caregiver that was present at the facility.
NAME OF LICENSING PROGRAM MANAGER: Troy Agard
NAME OF LICENSING PROGRAM ANALYST: Gina Saucedo
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2025
LIC809 (FAS) - (06/04)
Page: 3 of 10
Document Has Been Signed on 10/07/2025 02:19 PM - It Cannot Be Edited


Created By: Gina Saucedo On 10/07/2025 at 11:22 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., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: PRIMROSE 3
FACILITY NUMBER: 197609947

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/07/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87355(d)(3)
Criminal Record Clearance
(3) The licensee shall submit these fingerprints to the California Department of Justice, along with a second set of fingerprints for the purpose of searching the records of the Federal Bureau of Investigation, or comply with Section 87355(c), prior to the individual's employment, residence, or initial presence in the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on the record review the licensee did not comply with the section cited above in one (1) out of two (2) staff did not have fingerprinting/criminal form in their file which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/08/2025
Plan of Correction
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2
3
4
The licensee/administrator shall send fingerprinting/criminal record to Community Care Licensing Department for one (1) staff currently working at the faclity.
Type A
Section Cited
HSC
1569.69(a)(3)
Other Provisions
(a) Each residential care facility for the elderly licensed under this chapter shall ensure that each employee of the facility who assists residents with the self-administration of medications meets all of the following training requirements: (3) An employee shall be required to complete the training requirements for hands-on shadowing training described in this subdivision prior to assisting any resident in the self-administration of medications. The training and instruction described in this subdivision shall be completed, in their entirety, within the first two weeks of employment.

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 two (2) out of two (2) staff did not have medication training in their file which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/08/2025
Plan of Correction
1
2
3
4
The licensee/administrator shall send the medication training of the staff providing medication to the residents to Community Care Licensing Department for both staff currently working at the faclity.
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:
Gina Saucedo
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/07/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/07/2025


LIC809 (FAS) - (06/04)
Page: 4 of 10
Document Has Been Signed on 10/07/2025 02:19 PM - It Cannot Be Edited


Created By: Gina Saucedo On 10/07/2025 at 11:22 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., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: PRIMROSE 3
FACILITY NUMBER: 197609947

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/07/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.618(a)
Other Provisions
(a) The administrator designated by the licensee pursuant to paragraph (11) of subdivision (a) of Section 1569.15 shall be present at the facility during normal working hours. A facility manager designated by the licensee with notice to the department, shall be responsible for the operation of the facility when the administrator is temporarily absent from the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on the interview the licensee did not comply with the section cited above in not leaving someone responsible for the operation of the facility while being out of town which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/21/2025
Plan of Correction
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The administrator/licensee shall send a designee form to Community Care Licensing Department on who is in charge while they are currently out of town.
Type B
Section Cited
CCR
87412(a)(6)(A)
Personnel Records
(A) For administrators this shall include verification that he/she meets the educational requirements in Section 87405(d) through (g).

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on the record review the licensee did not comply with the section cited above in two (2) out of two (2) staff did not have their a job application in their file thus showing their educational requirements which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/21/2025
Plan of Correction
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2
3
4
The administrator/licensee shall send a copy of the job application which shows their education requirements of the two (2) staff currently working to the Community Care Licensing Department.
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:
Gina Saucedo
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/07/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/07/2025


LIC809 (FAS) - (06/04)
Page: 5 of 10
Document Has Been Signed on 10/07/2025 02:19 PM - It Cannot Be Edited


Created By: Gina Saucedo On 10/07/2025 at 11:22 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., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: PRIMROSE 3
FACILITY NUMBER: 197609947

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/07/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.625(b)(1)
Other Provisions
(1) The department shall adopt regulations to require staff members of residential care facilities for the elderly who assist residents with personal activities of daily living to receive appropriate training. This training shall consist of 40 hours of training. A staff member shall complete 20 hours, including six hours specific to dementia care, as required by subdivision (a) of Section 1569.626 and four hours specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696, before working independently with residents. The remaining 20 hours shall include six hours specific to dementia care and shall be completed within the first four weeks of employment. The training coursework may utilize various methods of instruction, including, but not limited to, lectures, instructional videos, and interactive online courses. The additional 16 hours shall be hands-on training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on the record review the licensee did not comply with the section cited above in two (2) out of two (2) staff did not have proper/all of their training in their file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/21/2025
Plan of Correction
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2
3
4
The administrator/licensee shall send two (2) of the staff trainings of two (2) of the staff currently working at the above facility to Community Care Licensing Department.

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:
Gina Saucedo
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/07/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/07/2025


LIC809 (FAS) - (06/04)
Page: 6 of 10
Document Has Been Signed on 10/07/2025 02:19 PM - It Cannot Be Edited


Created By: Gina Saucedo On 10/07/2025 at 11:22 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., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: PRIMROSE 3
FACILITY NUMBER: 197609947

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/07/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87506(b)(17)(B)
Resident Records
(b) Each resident's record shall contain at least the following information: (17) Documents and information required by the following: (B) Section 87459, Functional Capabilities;

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on the record review the licensee did not comply with the section cited above in five (5) out of five (5) residents did not have their functional capabiliies form in their file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/21/2025
Plan of Correction
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2
3
4
The administrator/licensee shall put in the residents file their functional capabilities form and send a copy to Community Care Licensing Department.
Type B
Section Cited
CCR
87506(b)(17)(E)
Resident Records
(b) Each resident's record shall contain at least the following information: (17) Documents and information required by the following: (E) Section 87463, Reappraisals; and

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on the record review the licensee did not comply with the section cited above in five (5) out of five (5) residents did not have their resident reappraisal form in their file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/21/2025
Plan of Correction
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2
3
4
The administrator/licensee shall put in the residents file their resident reappaisal form and send a copy to Community Care Licensing Department.
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:
Gina Saucedo
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/07/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/07/2025


LIC809 (FAS) - (06/04)
Page: 7 of 10
Document Has Been Signed on 10/07/2025 02:19 PM - It Cannot Be Edited


Created By: Gina Saucedo On 10/07/2025 at 11:22 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., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: PRIMROSE 3
FACILITY NUMBER: 197609947

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/07/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87456(a)(2)
Evaluation of Suitability for Admission
(a) Prior to accepting a resident for care and in order to evaluate his/her suitability, the facility shall, as specified in this article 8: (2) Perform a pre-admission appraisal.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on the record review the licensee did not comply with the section cited above in one (1) resident did not have their pre-placement pre-admission appraisal which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/21/2025
Plan of Correction
1
2
3
4
The administrator/licensee shall put in the residents file their pre-placement pre-admission appraisal and send a copy to Community Care Licensing Department.
Type B
Section Cited
CCR
87458(a)
Medical Assessment
(a) Prior to a person's acceptance as a resident, the licensee shall obtain documentation of a medical assessment, signed by a licensed medical professional acting within the scope of their practice and made within the last year, to be kept in the resident's record.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on the record review the licensee did not comply with the section cited above in one (1) resident did not have their medical assessment/physician's report which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/21/2025
Plan of Correction
1
2
3
4
The administrator/licensee shall put in the residents file their medical assessment/physician's report and send a copy to Community Care Licensing Department.
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:
Gina Saucedo
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/07/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/07/2025


LIC809 (FAS) - (06/04)
Page: 8 of 10
Document Has Been Signed on 10/07/2025 02:19 PM - It Cannot Be Edited


Created By: Gina Saucedo On 10/07/2025 at 11:22 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., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: PRIMROSE 3
FACILITY NUMBER: 197609947

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/07/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(e)(2)
Other Provisions
(e) A facility shall have all of the following information readily available to facility staff during an emergency: (2) An appraisal of resident needs and services plan for each resident.

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 three (3) out of six (6) residents did not have their needs and services plan which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/21/2025
Plan of Correction
1
2
3
4
The administrator/licensee shall put in the residents file their needs and services plan and send a copy to Community Care Licensing Department.
Type B
Section Cited
CCR
87458(c)(1)(8)


This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on the record review the licensee did not comply with the section cited above in which one (1) resident did not have their tuberculosis poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/21/2025
Plan of Correction
1
2
3
4
The administrator/licensee shall put in the residents file their tuberculosis results and send a copy to Community Care Licensing Department.
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:
Gina Saucedo
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/07/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/07/2025


LIC809 (FAS) - (06/04)
Page: 9 of 10
Document Has Been Signed on 10/07/2025 02:19 PM - It Cannot Be Edited


Created By: Gina Saucedo On 10/07/2025 at 12:01 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: PRIMROSE 3
FACILITY NUMBER: 197609947

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/07/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87211(a)
(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following:

(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on the observation, interview and record review the licensee did not comply with one (1) person being sent to the hospital without notifying Community Care Licensing Department and another resident's death was also not reported to Community Care Licensing Department which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/21/2025
Plan of Correction
1
2
3
4
The administrator/Licensee shall send the resident's death report that passed away and shall send an unusual incident report of current resident in the hospital to Community Care Licensing Department.
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:
Gina Saucedo
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/07/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/07/2025


LIC809 (FAS) - (06/04)
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