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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610443
Report Date: 08/13/2025
Date Signed: 08/13/2025 04:11:34 PM

Document Has Been Signed on 08/13/2025 04:11 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.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:LAKE VIEW RCFEFACILITY NUMBER:
197610443
ADMINISTRATOR/
DIRECTOR:		SIEGFREDO PLAZO JRFACILITY TYPE:
740
ADDRESS:35940 TIERRA SUBIDA AVETELEPHONE:
(818) 423-8821
CITY:PALMDALESTATE: CAZIP CODE:
93551
CAPACITY: 6CENSUS: 1DATE:
08/13/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Mabernadette Sayno and Jaime DelfinTIME VISIT/
INSPECTION COMPLETED:
03:30 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) Melissa Spaeth conducted an unannounced annual visit on 8/13/2025 and was greeted by the two caregivers. LPA stated the purpose of the visit was to conduct an annual inspection. Staff confirmed there is one resident living in the facility. The facility is licensed for six non-ambulatory residents. Room 1 is for staff use only, Room 2 for two non-ambulatory, Rooms 3 & 4 for one non-ambulatory, and Room 5 for one bedridden and one non-ambulatory resident.

LPA and the staff member toured the facility 10:20 am until 11:00 am.

Living/Dining Room – LPA observed the living room and dining room are combined. The living room area consists of comfortable seating. The dining room contained a dining room table with chairs. LPA observed a wood stove insertion within a lower level fireplace. The area was surrounded by a metal fencing that was locked.



Kitchen - The facility contained a seven day supply of non-perishable food and a two day supply of perishable foods. A locked kitchen cabinet contained resident medication containers and the first aid kit. The knives were locked in a drawer. A fire extinguisher is also located in the kitchen. The cleaning solutions were locked underneath the sink.

Staff Room– The staff room was locked.

Continued on 809-C
NAME OF LICENSING PROGRAM MANAGER: Troy Agard
NAME OF LICENSING PROGRAM ANALYST: Melissa Spaeth
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 08/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/13/2025
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 6
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 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: LAKE VIEW RCFE
FACILITY NUMBER: 197610443
VISIT DATE: 08/13/2025
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
Backyard - The backyard is a two level area which consists of a upper and lower area. The upper area is a shaded area which contains comfortable seating. The lower area is surrounded by a locked gated area in order to ensure the safety of the residents. The side gate leading from the backyard to the front yard was not locked.

Bedrooms - There are four bedrooms (Room 2, 3, 4, and 5) which contained bed, linens, night stand, lamp, chest of drawers, and a chair.

Bathrooms- There are three bathrooms which contained hand soap, paper towels, trash can, grab bars, and slip resistant mats.

Garage- LPA observed four locked metal storage closets which contained additional hygiene items, non-perishable and emergency food items, and cleaning solutions. The washer and dryer are located in the garage.

Water Temperature - LPA tested the water temperature at 10:50 am and was 122 degrees F. The hot water heater's temperature was adjusted. LPA tested the water again at 11:10 am and the water temperature was 111 degrees F.

Smoke and Carbon Monoxide Detectors - The detectors were tested at 11:30 am and were operable.

Resident Files - LPA spoke to the Administrator who stated the resident's file was not at the facility.

Staff Files - LPA reviewed the staff files at 11:35 am until 11:50 am.

Medications - LPA reviewed the resident medications at time.

Pursuant to Title 22, California Code of Regulations, deficiencies will be cited (refer to LIC 809-D. Exit interview conducted, appeal rights discussed, and a copy of the report was given.
NAME OF LICENSING PROGRAM MANAGER: Troy Agard
NAME OF LICENSING PROGRAM ANALYST: Melissa Spaeth
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2025
LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 08/13/2025 04:11 PM - It Cannot Be Edited


Created By: Melissa Spaeth On 08/13/2025 at 01:53 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: LAKE VIEW RCFE
FACILITY NUMBER: 197610443

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/13/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87506(b)(15)
Resident Records
(b) Each resident's record shall contain at least the following information: (15) The admission agreement and pre-admission appraisal, specified in Sections 87507, Admission Agreements and 87457, Pre-admission Appraisal.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA Spaeth's observations, the licensee did not comply with the section cited above by not obtaining a signed admissions agreement for R1m which could pose a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/20/2025
Plan of Correction
1
2
3
4
The Administrator will obtain a signed Admissions Agreement from R1 and forward to LPA Spaeth via email.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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:
Melissa Spaeth
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/13/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/13/2025


LIC809 (FAS) - (06/04)
Page: 4 of 6
Document Has Been Signed on 08/13/2025 04:11 PM - It Cannot Be Edited


Created By: Melissa Spaeth On 08/13/2025 at 02:17 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: LAKE VIEW RCFE
FACILITY NUMBER: 197610443

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/13/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(j)
87705 Care of Persons...(j) the licensee shall have an auditory device...to monitor exits....

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA's observation, the licensee did not comply with the section cited above. The delayed egress mechanisms were not working on four exit doors which poses an immediate health, safety or personal rights risks to persons in care.
POC Due Date: 08/15/2025
Plan of Correction
1
2
3
4
The Administrator will send a video of each door when opened does have the proper alarm on the door. The Administrator will send the four videos to LPA's cell phone.
Type A
Section Cited
HSC
1569.72(c)
1569.72(c) …bedridden persons may be admitted to, and remain in, residential care facilities for the elderly that secure and maintain an appropriate fire clearance. A fire clearance shall be issued to a facility…

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA's observation, the licensee did not comply with the section cited above. R1 was not in the correct room, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/15/2025
Plan of Correction
1
2
3
4
R1 will be moved to Room 5. The Administrator will send a snapshot showing R1 was moved from Room 1 to Room 5. The snapshot will be sent to LPA's phone (818-421-2278).
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:
Melissa Spaeth
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/13/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/13/2025


LIC809 (FAS) - (06/04)
Page: 5 of 6
Document Has Been Signed on 08/13/2025 04:11 PM - It Cannot Be Edited


Created By: Melissa Spaeth On 08/13/2025 at 02:24 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: LAKE VIEW RCFE
FACILITY NUMBER: 197610443

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/13/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(c)(2)
87303 Maintenance..(e) Water supplies…shall be maintained as following: (2) Faucets used by residents…shall deliver hot water. Hot water temperature…of not more than 120 degrees F.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA's observation, the licensee did not comply with the section cited above. The hot water temperature was 122 degres F which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/13/2025
Plan of Correction
1
2
3
4
During LPA's visit, the water temperature was adjusted. LPA tested the water temperature at 11:45 am and the temperature was 111 degrees F. The deficiency was corrected during LPA's visit.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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:
Melissa Spaeth
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/13/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/13/2025


LIC809 (FAS) - (06/04)
Page: 6 of 6