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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610169
Report Date: 10/01/2025
Date Signed: 10/01/2025 01:18:38 PM

Document Has Been Signed on 10/01/2025 01:18 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:BEYOND A HOME LLCFACILITY NUMBER:
197610169
ADMINISTRATOR/
DIRECTOR:		RICHARDSON, KESHAFACILITY TYPE:
740
ADDRESS:6023 WEST AVE L 12TELEPHONE:
(661) 860-5048
CITY:LANCASTERSTATE: CAZIP CODE:
93536
CAPACITY: 6CENSUS: 6DATE:
10/01/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:47 AM
MET WITH:Kesha Richardson - AdministratorTIME VISIT/
INSPECTION COMPLETED:
01:00 PM
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On 10/1/2025 Licensing Program Analyst (LPA) Perchui Milena Khurshudyan arrived at this facility to conduct the required Annual Inspection. Upon arrival, LPA was greeted by the Caregiver Shela Ferencz, who granted access to the facility. LPA explained the reason for the visit. Facility Administrator Kesha Richardson arrived shortly after. LPA Khurshudyan reviewed the required postings on the hallway next to the entrance area and requested staff and residents’ rosters for review.

The inspection tool was used to complete the visit.

At 12:00pm 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 seven (7) bedrooms, of which six (6) bedrooms are designated for residents’ private use, and one (1) office/staff room. There are three (3) bathrooms, a kitchen, common areas: living and dining rooms, and an outdoor area. Facility has an approved fire clearance for six (6) Non-ambulatory residents, of which one (1) can be bedridden in rooms #2,3,4, and a Hospice waiver approval for six (6) residents.

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 inside the locked kitchen cabinet. Emergency supply of food / water was stored inside the pantry. Food storage and preparation areas are clean and inaccessible to pests. LPA observed two (2) fire extinguishers throughout the facility. The fire extinguishers were last serviced on 9/19/2024, LPA was informed that new service date is already scheduled for the following week. A weekly menu was also available for residents. The second refrigerator was also available in the garage for additional food supply. Dish soap and other chemicals were properly stored and locked inside separate closet located in the hallway.

Continue on LIC809-C

NAME OF LICENSING PROGRAM MANAGER: Nichelle Gillyard
NAME OF LICENSING PROGRAM ANALYST: Perchui Khurshudyan
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 10/01/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/01/2025
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)
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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: BEYOND A HOME LLC
FACILITY NUMBER: 197610169
VISIT DATE: 10/01/2025
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Bedrooms: There are seven (7) bedrooms in the facility. All bedrooms are for residents’ use. LPA observed bedrooms to be properly furnished with beds, linens, night stands, chairs, drawers, closets, and adequate lighting. All bedrooms appeared organized and clean. Residents have enough personal hygiene products.

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 12:15pm, LPA measured the room temperature to be 78 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 three (3) 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 12:25pm to be 119.4 degrees Fahrenheit. The bathrooms were checked for cleanliness and proper operations. Towels and washcloths are not shared.

Smoke and Carbon Monoxide Detectors: The smoke and carbon monoxide detectors were tested by staff at 12:35pm and were observed to be operational.

Garage: The garage is currently being used for storage.

Laundry Room: Functioning washer and dryer are located in a separate laundry room located in the hallway. Laundry detergents and other chemical supplies are locked and inaccessible to clients in care.

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

Staff/Client File review: Facility records are kept inside the locked commercial cabinets located in the office/staff room. Between 10:35am -11:55am LPA conducted records review of five (5) staff files and six (6) residents’ records. Files were complete and updated.

Continue on LIC809C

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

DATE: 10/01/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/01/2025
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: BEYOND A HOME LLC
FACILITY NUMBER: 197610169
VISIT DATE: 10/01/2025
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Medications: At approximately 12:35pm. 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 medication closet and inaccessible to residents in care. Complete First-aid kit is also available and placed in the common area. No potentially dangerous items were found in the facility. The facility operates with three (3) shifts and has two to three (2-3) staff members for each shift.

LPA conducted an interview with an Administrator, one (1) caregiver and two (2) out of six (6) residents who were able to communicate.

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

LPA collected LIC500, LIC9020, and a copy of Certificate of Liability Insurance.

Liability Insurance - Exp 12/21/2025

The Administrator's certificate - Exp date is 9/30/2026.

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: 10/01/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/01/2025
LIC809 (FAS) - (06/04)
Page: 4 of 4