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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610354
Report Date: 04/08/2025
Date Signed: 04/15/2025 10:41:10 AM

Document Has Been Signed on 04/15/2025 10:41 AM - 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:PENDLETON HOUSEFACILITY NUMBER:
197610354
ADMINISTRATOR/
DIRECTOR:		KARIBIAN, MARY MAROFACILITY TYPE:
740
ADDRESS:12016 PENDLETON STREETTELEPHONE:
(818) 822-0911
CITY:SUN VALLEYSTATE: CAZIP CODE:
91352
CAPACITY: 6CENSUS: 6DATE:
04/08/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:35 AM
MET WITH:Karibian, Mary Maro, AdministratorTIME VISIT/
INSPECTION COMPLETED:
02:45 PM
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On 04/08/2025, Licensing Program Analyst (LPA) de la Cerra arrived at the facility at 10:30am to conduct an unannounced annual inspection. LPA met with the facility administrator and LPA informed administrator the purpose of the visit.

At approximately 11:00am LPA and administrator toured the facility and the following was observed. The facility is a single-story building that consist of five (5) bedrooms and two (2) bathrooms. LPA observed one (1) fully charged fire extinguisher. LPA observed the required facility postings in the common area. The facility provides a telephone for clients to use and LPA observed the phone to be operational.

LPA observed dual smoke/carbon monoxide detectors that are hard wired and interconnected. Administrator tested the dual smoke/carbon monoxide detector @11:50am and was observed to be operational.

Bedrooms: There is one (1) bedroom for staff use and four (4) bedrooms designated for residents to use. Resident rooms were observed to have sufficient lighting. All bedrooms are furnished with a night stand, a chair, a lamp, a closet and a bed with clean bedding and linens.

Bathrooms: LPA observed two (2) bathrooms that are in good repair. The hot water temperature measured between 106°- 109°F. LPA observed the appropriate grab bars by the toilet and in the shower area. LPA observed the appropriate non-skid mats in each bathroom.

Common Areas: The living room appeared clean and were properly furnished. No obstructions and or tripping hazards throughout the facility.

NAME OF LICENSING PROGRAM MANAGER: Naira Margaryan
NAME OF LICENSING PROGRAM ANALYST: Leizl De La Cerra
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/08/2025
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: PENDLETON HOUSE
FACILITY NUMBER: 197610354
VISIT DATE: 04/08/2025
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KITCHEN: The facility has a kitchen area that is equipped with a refrigerator, stove and microwave. There is an adequate supply of perishable and nonperishable food and dining ware to accommodate a maximum capacity of six (6). Sharps and knives were observed locked in a kitchen cabinet.

Laundry Area: LPA also observed the washer and dryer located in the detached garage and both appear to be in good condition. LPA also observed a locked cabinet that stores laundry detergents and some cleaning solutions,

Surrounding grounds: No bodies of water observed at this facility. LPA observed 2 seating areas for residents to use. The backyard seating area is shaded and both seating areas has furniture to accommodate the residents. The passageways and entrance to the home was clear of obstruction.

Facility Records: At 1:00pm LPA conducted review of residents’ records and staff records.

LPA reviewed six (6) out of six (6) client records and two (2) staff records to ensure compliance. The facility files were kept in locked cabinet located in the common area.

Medications: The medications were kept in locked cabinet in the common area and is inaccessible to residents in care. The first-aid kit is complete.

At approximately 1:51pm medications and medication records for two (2) residents were reviewed for proper documentation. Centrally Stored Medication Records are pre-filled by pharmacy and facility keeps a Medication Administration Record (MAR).

Administrative: LPA received copies of the following; LIC 500, LIC 9020, liability insurance and administrator certificate.

No deficiencies cited during today's visit. Copy of this report, was provided to the administrator.

NAME OF LICENSING PROGRAM MANAGER: Naira Margaryan
NAME OF LICENSING PROGRAM ANALYST: Leizl De La Cerra
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2025
LIC809 (FAS) - (06/04)
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