197610253-10-7-2025-31-AS-MCAA-DM8TKE-20251007144748

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610253
Report Date: 10/07/2025
Date Signed: 10/07/2025 02:48:36 PM

Document Has Been Signed on 10/07/2025 02:48 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:	ASSURECARE HOME INC		FACILITY NUMBER:	197610253
ADMINISTRATOR/ DIRECTOR:	PELEGRINO, FLORENCE C		FACILITY TYPE:	740
ADDRESS:	16729 TULSA ST		TELEPHONE:	(747) 239-3219
CITY:	GRANADA HILLS	STATE: CA	ZIP CODE:	91344
CAPACITY: 6		CENSUS: 5	DATE:	10/07/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	11:22 AM
MET WITH:	Adela Cahayon		TIME VISIT/ INSPECTION COMPLETED:	03:00 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) Michael Cava conducted an Annual Required visit and inspection of the facility. LPA met with staff, Adele Cahayon, and explained the reason for the visit. At approximately 11:30am, with the assistance of staff, LPA took a tour of the physical plant. The facility is a one story building. Required postings were observed in the entry area. The smoke alarms and carbon monoxide detectors are dual and interconnected. The fire extinguisher is located by the entrance. Kitchen: The kitchen appliances and fixtures were functional. LPA found a sufficient amount of perishable and non-perishable food at the facility that is properly sealed and stored. Knives are kept locked in a kitchen drawer. Cleaning supplies are kept locked in a cabinet underneath the sink. Bedrooms: There are five (5) bedrooms, of which four (4) is used for residents and one (1) is a staff room. The bedrooms, in use by residents were properly furnished with appropriate beddings and linens with sufficient lighting. Passageways from resident rooms were clear of any obstruction. Bathrooms: There are two (2) bathrooms designated for residents' use. Both bathrooms were properly supplied with non-slip mats and had functional fixtures. Hot water temperature was measured between 107 to 110 degrees Fahrenheit.

NAME OF LICENSING PROGRAM MANAGER: Naira Margaryan
NAME OF LICENSING PROGRAM ANALYST: Michael Cava
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)

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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: ASSURECARE HOME INC	FACILITY NUMBER: 197610253
	VISIT DATE: 10/07/2025

NARRATIVE

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Common Areas: These included the living room and dining area. The living room is furnished with a table, couches, recliners and a television. The table in the dining room is large enough to seat the six (6) residents. Furniture is observed to be maintained and in good repair. Floors are mopped and clean. Passageways are clear of obstruction. The auditory alarms at all exit doors were on and functional at the time of the visit.

Surrounding Grounds: Pathways in the front and backyards were free of obstruction. There is furniture appropriate for outdoor use. The outdoor area was free of hazards.

Laundry Room: The laundry room is located by the kitchen. There is a locked door to the laundry area that is kept locked at all times as detergents and softeners are maintained there.

Garage: The garage is attached to the home. It is used as additional storage space. No resident access

Staff Work Station: Staff work station is located at a corner by the dining room. There is a cabinet where both resident and staff records are filed.

Resident Files: LPA conducted a file review of resident records to insure compliance of licensing forms.

Staff Files: LPA also conducted a file review of staff records to insure compliance with licensing forms.

Medications: Medications are stored locked in one of the kitchen cabinets. Medication and Medication Records were review for proper storage and documentation.

Pursuant to Title 22 Division 6 of the CA Code of Regulations, there were no deficiencies observed during the visit. Exit Interview Conducted and a copy of this report issued.

NAME OF LICENSING PROGRAM MANAGER: Naira Margaryan
NAME OF LICENSING PROGRAM ANALYST: Michael Cava
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)

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