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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610166
Report Date: 07/28/2025
Date Signed: 07/28/2025 12:10:01 PM

Document Has Been Signed on 07/28/2025 12:10 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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:QUARTZ HAVENFACILITY NUMBER:
197610166
ADMINISTRATOR/
DIRECTOR:		AYLLON, MADELEINEFACILITY TYPE:
740
ADDRESS:7250 QUARTZ AVETELEPHONE:
(626) 373-4386
CITY:WINNETKASTATE: CAZIP CODE:
91306
CAPACITY: 6CENSUS: 5DATE:
07/28/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:50 AM
MET WITH:Dunhill Tolentino- CaregiverTIME VISIT/
INSPECTION COMPLETED:
12:20 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
On 7/28/2025, Licensing Program Analyst (LPA) Perchui Milena Khurshudyan arrived at this facility to conduct a required Annual Inspection. Upon arrival LPA was greeted by the Caregiver Dunhill Tolantino, who granted access to the facility. LPA introduced herself by showing her department badge and explained the reason for the visit. The facility Administrator was contacted by phone. LPA Khurshudyan reviewed the required postings on a wall throughout the facility. The inspection tool was used to complete today's visit.

At 9:45am LPA, with the help of the caregiver, began a physical plant tour of the facility and the following was observed: This is a single-story building with four (4) bedrooms, two (2) bathrooms, kitchen, garage, common areas, and outdoor areas. This facility is a Residential Care Facility for the Elderly (RCFE). A fire clearance was approved for six (6) Non-Ambulatory residents and one (1) Bedridden resident. The facility also has Hospice waiver for three (3) residents. The smoke alarms and carbon monoxide detectors are hard wired and inter-connected; they were tested and are operational. The facility has two (2) fire extinguishers that were last service on 3/10/2025: the first one is located by the entrance, on the wall, and the second one is located inside the bedroom #2.

Kitchen: LPA observed a seven-day supply of non-perishable food, and a two-day supply of perishable food properly stored and labeled. No expired food was observed. Facility stores knives and sharps under the sink inside the locked cabinet. An emergency supply of food / water was stored inside the kitchen cabinets and pantry. Food storage and preparation areas are clean and inaccessible to pests. A weekly menu was also available for clients.

Continue on LIC809-C

NAME OF LICENSING PROGRAM MANAGER: Nichelle Gillyard
NAME OF LICENSING PROGRAM ANALYST: Perchui Khurshudyan
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/28/2025
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: QUARTZ HAVEN
FACILITY NUMBER: 197610166
VISIT DATE: 07/28/2025
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: There are four (4) bedrooms in the facility, of which three (3) are designated for clients use and one (1) bedroom for staff use only. Residents’ bedrooms are shared. LPA observed bedrooms to be properly furnished with beds, linens, night stands, chairs, drawers, closets, and adequate lighting. All bedrooms appeared organized and clean.

Common Areas: These include living and dining areas. LPA observed dining, living areas clean and clear of clutter. Furniture is generally new and in a good repair. Dining and living room furniture sits at the capacity of the facility. Walls, floors, windows, screens, and blinds were clean and in good repair. At 10:20am, LPA measured the room temperature to be 74 degrees Fahrenheit. There is a linen closet with an adequate supply of fresh linens ready to use. No obstructions and or tripping hazards found throughout the facility. Facility has landline, LPA checked it was operational. There is a television, cabinet for activities, books and art supplies available for clients’ use.

Bathroom: There are two (2) bathrooms in the facility. The bathrooms contained hand soap, paper towels, toilet paper and trash bins with lids. The hot water temperature was measured at approximately 11:05am to be 111.7 degrees Fahrenheit. LPA also observed required signs on the bathroom walls and non-skid mats inside the showers.

Garage: LPA observed the garage is attached to the facility and is currently being used as storage for PPE supplies and for emergency water.

Laundry Room: Functioning washer and dryer located adjacent to kitchen area inside the locked closet. The laundry detergents and other chemical supplies are also locked inside the closet and inaccessible to clients in care.

Backyard: LPA observed sufficient yard space and fenced backyard. Appropriately covered shaded area available for clients to rest. LPA discussed the importance of maintaining the care and supervision to meet the needs of clients. Exit doors were unlocked and free of obstructions. There is no body of water in the property.

Continue on LIC809-C

NAME OF LICENSING PROGRAM MANAGER: Nichelle Gillyard
NAME OF LICENSING PROGRAM ANALYST: Perchui Khurshudyan
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2025
LIC809 (FAS) - (06/04)
Page: 3 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: QUARTZ HAVEN
FACILITY NUMBER: 197610166
VISIT DATE: 07/28/2025
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
Staff/Client File review: Facility records are kept inside the locked cabinets located between the kitchen and dining areas. Between 11:15am -12:00pm LPA conducted records review of four (4) staff files and five (5) residents’ records. Files were complete and updated.

Medications: At approximately 12:05pm. LPA reviewed Centrally Stored Medication Destruction Records for proper documentation. The facility also maintains Medical Administration Records (MAR). LPA observed centrally stored medications locked inside the kitchen cabinet and inaccessible to clients in care. Complete First-aid kit is also located in the same kitchen cabinet, new manual for first aid kit was also available. No potentially dangerous items were found in the facility. The facility operates with two (2) shifts and has two / three staff members for each shift.

All residents were present during the visit, LPA attempted to interview all residents and the Caregivers.

Facility plan/sketch is posted on the entrance wall along with other posting requirements.

LPA collected LIC500, LIC9020, and the Liability Insurance Certificate copy

The Administrator's certificate - Exp date is 2/13/2027.

Liability Insurance - Expires 07/22/2026.

LPA informed the Administrator that License Annual Fee is past due: Due date was 7/16/25 for the amount $495.00. LPA also provided the PIN 667713 for online payment.

No citations issued during today's visit.

Exit interview conducted. Copy of this report provided.

NAME OF LICENSING PROGRAM MANAGER: Nichelle Gillyard
NAME OF LICENSING PROGRAM ANALYST: Perchui Khurshudyan
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2025
LIC809 (FAS) - (06/04)
Page: 4 of 4