<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610161
Report Date: 09/30/2025
Date Signed: 09/30/2025 04:08:30 PM

Document Has Been Signed on 09/30/2025 04:08 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:BETD SAN FERNANDO CARE LLCFACILITY NUMBER:
197610161
ADMINISTRATOR/
DIRECTOR:		TIKU, ELIZABETH A.FACILITY TYPE:
740
ADDRESS:628 NORTH LAZARD STREETTELEPHONE:
(818) 493-8351
CITY:SAN FERNANDOSTATE: CAZIP CODE:
91340
CAPACITY: 6CENSUS: 4DATE:
09/30/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Elizabeth Tiku-AdministratorTIME VISIT/
INSPECTION COMPLETED:
04:00 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Nadia Shahbazian met with Elizabeth Tiku for an Annual Required visit and inspection of the facility. LPA explained the reason for the visit. The facility is a one story home, located in a residential neighborhood and consists of five (05) bedrooms, of which one (01) bedroom is for staff, and three (03) bathrooms. This Residential Care for Elderly (RCFE) is approved for residents ages 60 and above. Facility is fire cleared for one (01) ambulatory, five (05) non-ambulatory residents, of which one (01) may be bedridden in room #3 and a hospice waiver for six (06) residents. Currently there is one (1) resident on hospice.

At 12:15pm, with the assistance of administrator, LPA took a tour of the physical plant.

Required postings were observed in the dining room. The smoke/carbon monoxide detectors are hardwired and interconnected. At 12:30pm smoke/carbon monoxide detectors were posted and observed to function properly. The fire extinguisher is located in the kitchen with purchase date of 10/30/2024.

Common Areas: These included the living room and dining room. The common areas were properly furnished with tables, chairs, sofas. There is a television set and a cabinet with games in the living room. There is a linen closet in the hallway, next to bedroom # 1. Facility provides internet and cable access .

Kitchen: The kitchen appliances and fixtures were functional and consisted on stove, oven, refrigerator, microwave and dishwasher. Kitchen surfaces and appliances are clean and food is marked purchase or expiration dates. LPA found a sufficient supply of perishable (2 days) and non-perishable (7 days) foods at the facility, with plenty of dishes in the cupboards. Knives and sharp objects were stored in a locked cabinet in the kitchen.

(Continued on LIC 809-C)
NAME OF LICENSING PROGRAM MANAGER: Troy Agard
NAME OF LICENSING PROGRAM ANALYST: Nadia Shahbazian
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/30/2025
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 4
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 4
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: BETD SAN FERNANDO CARE LLC
FACILITY NUMBER: 197610161
VISIT DATE: 09/30/2025
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Bedrooms/Bathrooms: There were five (5) total bedrooms but bedroom #2 is currently used as office/staff bedroom. All of the bedrooms, in use by residents were were properly furnished with appropriate beddings, chairs, cabinets and sufficient lighting and linens. There are three (3) bathrooms designated for staff and residents' use. All bathrooms were properly supplied and had functional fixtures and required non-skid mats. Hot water temperature was measured between 114.1 and 122.4 degrees Fahrenheit.

Surrounding Grounds: There are no bodies of water present. There are exit doors in bedrooms 3, 4, and 5, and in the kitchen, leading to the backyard. Facility uses the main door as the emergency exit but there is a side gate as emergency exit, as well. All walkways and exit passages were free of obstruction. There is patio furniture with an umbrella, appropriate for outdoor use. There is an attached garage, currently used as storage. LPA observed a refrigerator for staff use in the garage. There are locked cabinets for storage of chemicals and detergents, and a washer and dryer in the garage. There is a locked storage room and a locked shed in the backyard for storing items.

Medications: Medication and Medication Records are kept locked in a kitchen cabinet. Medications for 2 out of 4 residents were counted and records were reviewed for accuracy of administration. LPA observed two first aid kits and a first aid manual in the medication cabinet.

Resident Files: LPA conducted a file review of all 4 resident records to ensure compliance of licensing forms, including physician records, appraisal and needs and other required documents.

Staff Files: LPA conducted a file review of staff records to ensure forms and training are up to date and compliant with licensing forms.

Pursuant to Title 22 Division 6 of the CA Code of Regulations, deficiencies observed during the visit. Citation and appeal rights were provided.

Exit Interview Conducted / A Copy of the Report Issued.

NAME OF LICENSING PROGRAM MANAGER: Troy Agard
NAME OF LICENSING PROGRAM ANALYST: Nadia Shahbazian
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2025
LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 09/30/2025 04:08 PM - It Cannot Be Edited


Created By: Nadia Shahbazian On 09/30/2025 at 03:29 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: BETD SAN FERNANDO CARE LLC
FACILITY NUMBER: 197610161

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/30/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(h)(5)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in maintaining the medications in original bottles, rather than storing in weekly pill boxes, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/30/2025
Plan of Correction
1
2
3
4
Administrator removed the pills from the weekly pill boxes and will ensure that medications are only removed from the original bottles, prior to administration. Administrator will ensure medications are kept in original bottles at all times.
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
1
2
3
4
Based on observation and record review, the licensee did not comply with the section cited above, in which 3 resident files did not have current physician reports, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/10/2025
Plan of Correction
1
2
3
4
Administrator will obtain current copies of physician records and will submit 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.
Troy Agard
NAME OF LICENSING PROGRAM MANAGER:
Nadia Shahbazian
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/30/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/30/2025


LIC809 (FAS) - (06/04)
Page: 4 of 4