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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610645
Report Date: 04/13/2026
Date Signed: 04/13/2026 04:07:21 PM

Document Has Been Signed on 04/13/2026 04:07 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:SONLEMA INCFACILITY NUMBER:
197610645
ADMINISTRATOR/
DIRECTOR:		HOVIK ODABASHYANFACILITY TYPE:
740
ADDRESS:6504 LINDLEY AVENUETELEPHONE:
(818) 747-8172
CITY:RESEDASTATE: CAZIP CODE:
91335
CAPACITY: 6CENSUS: 6DATE:
04/13/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:10 AM
MET WITH:Hovik Odabashyan, AdministratorTIME VISIT/
INSPECTION COMPLETED:
04:35 PM
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At 9:10 AM, Licensing Program Analyst (LPA), Huma Rahimi conducted an unannounced required annual inspection and met with the staff Liana Babaian who granted access to the facility. The staff contacted the Administrator via a telephone and LPA explained the reason for the visit. Today's site visit consisted of LPA touring the physical plant inside and outside and observed the following:

KITCHEN: The facility has a Kitchen area that is equipped with a refrigerator, oven, and a sink. Stove was observed in a good working condition. At 9:20 AM, LPA did not observe a seven day supply of non-perishable food and a two day supply of perishable foods. LPA observed almost empty (one cup remaining) gallon of milk, two eggs, opened and rotten fish container, two cauliflowers, and a quarter gallon of orange juice. Staff informed LPA that two residents did not have their breakfast yet. During the visit, at around 12:00 pm, LPA observed that Resident #6 (R6) requested for a glass of milk and the staff was unable to provide. Additionally, LPA observed a knife, a scissor, and staff's medication in one of the drawers in the kitchen unlocked and accessible to residents in care. LPA also observed that residents' medication were kept in the kitchen in two cabinets (upper & lower) of which the upper one was observed locked and the lower one was unlocked and accessible to residents in care. LPA observed another drawer in the kitchen where the rest of the sharps/knives were kept locked. LPA observed a Fire Extinguisher and was last purchased on 04/13/2026.

Continue on LIC 809C

NAME OF LICENSING PROGRAM MANAGER: Nichelle Gillyard
NAME OF LICENSING PROGRAM ANALYST: Huma Rahimi
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/13/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/13/2026
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: SONLEMA INC
FACILITY NUMBER: 197610645
VISIT DATE: 04/13/2026
NARRATIVE
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MEDICATION ROOM: The centrally stored medication were observed in two upper and lower cabinets of the kitchen and the upper cabinet was observed locked and the lower cabinet was unlocked and accessible to residents in care. LPA observed the residents and staff files locked in a locked cabinet in the living room.

BEDROOMS: There are three (3) bedrooms designated for residents use. All bedrooms are shared. LPA observed that all bedrooms are furnished with beds, dressers and required bedding and linen. The bedrooms have sufficient closet space and have sufficient lighting. Auditory alarms were tested and were observed to be operational. Furthermore, LPA observed the emergency exit in bedroom #2 (Bedridden room) to be completely blocked by a resident bed. Additionally, LPA observed resident medication to be unlocked to residents in bedroom #2 (bedridden). LPA observed Resident #1 (R1) with half bedrail and LPA asked the Administrator if there is a physician order and the Administrator stated that he did not know that he was supposed to have it. The facility has an awake staff.

BATHROOMS: There are three (3) bathrooms at the facility of which two are for residents' use and one for staff use. LPA observed the staff bathroom unlocked and accessible to residents in care with clorox on the top of the toilet tank, drain clog remover, disinfectant spray next to the toilet. LPA observed all bathrooms are clean and in good repair. Properly supplied with toilet papers, soap and paper towels. LPA observed appropriate grab bar and had non-skid mat The water temperature was noted at 112.5°. In one of the residents' bathroom, LPA observed under the sink cabinet to have a Clorox gallon and Awesome Bleach gallon and was observed unlocked and accessible to residents in care. Additionally, LPA observed A+D treat & heal cream in the bathroom drawer unlocked and accessible to residents in care.

LAUNDRY ROOM: The laundry room is located in the kitchen and all cleaning supplies and laundry detergents were observed tol be locked in standing closet by the laundry machines inaccessible to residents in care. The washer/dryer appear to be in good working condition.


Continue on LIC 809C
NAME OF LICENSING PROGRAM MANAGER: Nichelle Gillyard
NAME OF LICENSING PROGRAM ANALYST: Huma Rahimi
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/13/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/13/2026
LIC809 (FAS) - (06/04)
Page: 3 of 9
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: SONLEMA INC
FACILITY NUMBER: 197610645
VISIT DATE: 04/13/2026
NARRATIVE
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COMMON AREAS: The facility maintains a comfortable temperature at 73°F. The living room and dining area appeared clean and were properly furnished and has a television. Additionally, self-closing fire door was altered by taking out the door handle and was plastered completely and placed a air freshener spray in the middle of the door to prevent from closing during the emergency. The Administrator stated that he did not know and LPA explained the reason why the fire door is not supposed to be blocked or altered. No any other obstructions and or tripping hazards throughout the facility. LPA observed a working telephone for the facility.

SURROUNDING GROUNDS: The facility has sufficient backyard space. LPA did observe appropriate outdoor furniture in the backyard of the facility that can accommodate six (6) residents, LPA observe a covered shaded area for residents. There is no swimming pool or any bodies of water at the facility. The exit was free of any obstruction or hazard.

Garage/Storage: The facility does not have an extra space or a garage.

SMOKE DETECTORS/CARBON MONOXIDE. Smoke detectors and carbon monoxide were located throughout the facility. At 9:35 AM, they were tested and observed to be operational.

Between 11:30 AM to 1:15 PM, LPA reviewed records of six (6) residents and three (3) staff. LPA observed that Resident #1's (R1's) records were missing a TB test results and consent forms, Resident #2 (R2) records had a partially completed Appraisal Needs and Services Plan (LIC 625), Resident #3 (R3) records were missing a Physician report, TB test results, consent forms, and LIC 625, Resident #5 (R5) records were missing LIC 625 and TB test results, and Resident #6 (R6) records were missing ID information, consent forms, and LIC 625. During the staff file review, LPA observed that Staff #1 (S1) records were missing 1st Aid and CPR training, and in-service training. Staff #2 (S2) records were missing TB test results, 1st Aid and CPR training, in-service training and health screening form (LIC 503). Upon LPA's request for the Administrator facility file, the Administrator asked LPA if the Administrator is also supposed to have a facility file available for review. During the visit, LPA observed that the Administrator lacked knowledge of the title 22 regulations and rules and stated that he did not know.

Administrative: LPA collected LIC500.

Deficiencies issued during today's visit. Appeal rights explained.

Exit interview conducted and copy this report signed and delivered.

NAME OF LICENSING PROGRAM MANAGER: Nichelle Gillyard
NAME OF LICENSING PROGRAM ANALYST: Huma Rahimi
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/13/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/13/2026
LIC809 (FAS) - (06/04)
Page: 4 of 9
Document Has Been Signed on 04/13/2026 04:07 PM - It Cannot Be Edited


Created By: Huma Rahimi On 04/13/2026 at 02:41 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: SONLEMA INC
FACILITY NUMBER: 197610645

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/13/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(f)(2)
Care of Persons with Dementia (f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above by leaving medications, a knife, a scissor, and cleaning supplies (Clorox/bleach), unlocked and accessible to residents in care, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/15/2026
Plan of Correction
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Licensee agreed to conduct an in-house training with all staff regarding the care for Dementia residents and always keep all the medications, sharps, toxins locked. Proof of training will be emailed to LPA by POC date.
Type A
Section Cited
CCR
87202(a)
Fire Clearance (a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA’s observation the licensee did not comply with the section cited above by failing to maintain one (1) fire door between the living room and hallway in a good working condition and was prevented from closing by placing a air freshener spray, This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/15/2026
Plan of Correction
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Licensee/Administrator agreed to replace/fix one (1) fire door and submit and submit a picture of the invoice/fixed door to LPA by POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Nichelle Gillyard
NAME OF LICENSING PROGRAM MANAGER:
Huma Rahimi
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/13/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/13/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/13/2026 04:07 PM - It Cannot Be Edited


Created By: Huma Rahimi On 04/13/2026 at 02:43 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: SONLEMA INC
FACILITY NUMBER: 197610645

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/13/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87506(b)
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
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Based on LPA file review, the licensee did not comply with the section cited above by not completing six (6) out of six (6) resident files. Records were incomplete and or missing documents, which poses a potential health and safety risk to persons in care.
POC Due Date: 04/20/2026
Plan of Correction
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Licensee agreed to review and complete all facility residents' files. Written roster with resident name and date of file completion will be submitted to LPA by POC date.
Type B
Section Cited
CCR
87405(d)(1,2)
Administrator Qualifications - 87405 (d) The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7). If the licensee is also the administrator... (1) Knowledge of the requirements...
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interviews, and LPA's observation the licensee failed to ensure to demonstrate knowledge and requirement for appropriate care and supervision of the residents which poses a potential health and safety risk to the residents in care.
POC Due Date: 04/20/2026
Plan of Correction
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The Administrator agrees to follow proper guidelines for Administrator Qualifications. LPA discussed with the Administrators’ section 87405. The Administrator agrees to submit a written letter to CCL indicating that they have read the regulations, have full understanding
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Nichelle Gillyard
NAME OF LICENSING PROGRAM MANAGER:
Huma Rahimi
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/13/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/13/2026


LIC809 (FAS) - (06/04)
Page: 6 of 9
Document Has Been Signed on 04/13/2026 04:07 PM - It Cannot Be Edited


Created By: Huma Rahimi On 04/13/2026 at 02:56 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: SONLEMA INC
FACILITY NUMBER: 197610645

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/13/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87555(b)(28)
87555(b)(28) General Food Service Requirements All food shall be protected against contamination. Contaminated food shall be discarded immediately upon discovery.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based credible witness and LPA's observations the Licensee did not comply by having old/rotten fish in the refrigerator which poses a potential health and safety risk to the residents in care.
POC Due Date: 04/20/2026
Plan of Correction
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The Administrator has agreed to remove and discard the rotten foods from the refrigerator.
This part of the plan of correction met.
Type B
Section Cited
CCR
87307(d)(6)
Personal Accommodations and Services: (d) The following space and safety provisions shall apply to all facilities: (6) All outdoor and indoor passageways and stairways shall be kept free of obstruction.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA’s observation, licensee did not comply with the section cited above by blocking the exit door in the bedroom #2 (bedridden) by a resident’s bed. This poses a potential health and safety risk to residents in care.
POC Due Date: 04/20/2026
Plan of Correction
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During today's visit, the Administrator cleared the passageways from the obstruction in the bedroom #2. The Administrator also agreed to review the section cited and inform LPA via e-mail by POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Nichelle Gillyard
NAME OF LICENSING PROGRAM MANAGER:
Huma Rahimi
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/13/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/13/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/13/2026 04:07 PM - It Cannot Be Edited


Created By: Huma Rahimi On 04/13/2026 at 03:11 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: SONLEMA INC
FACILITY NUMBER: 197610645

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/13/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87608(a)(3)
Postural Support: (a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions: (3) A written order from a physician indicating the need for the postural support shall be maintained in the resident's record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation and record review, the licensee did not comply with the section cited above by having half bedrails for Resident #1 (R1) without Physician order. This poses an immediate health, safety to persons in care.
POC Due Date: 04/15/2026
Plan of Correction
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License/Administrator removed the half bedrails for Resident #1 (R1). POC cleared during the visit.
Type A
Section Cited
CCR
87458(c)(1)(A)
(c) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the licensed medical professional's diagnosis or diagnoses and results of an examination for all of the following: (A) Communicable tuberculosis.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above in 1 out of 1, all residents records were not available for LPA check for TB test which poses/posed an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/15/2026
Plan of Correction
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Licensee will ensure all residents has a TB test in their physician report (LIC 602).
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Nichelle Gillyard
NAME OF LICENSING PROGRAM MANAGER:
Huma Rahimi
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/13/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/13/2026


LIC809 (FAS) - (06/04)
Page: 8 of 9
Document Has Been Signed on 04/13/2026 04:07 PM - It Cannot Be Edited


Created By: Huma Rahimi On 04/13/2026 at 03:23 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: SONLEMA INC
FACILITY NUMBER: 197610645

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/13/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87555(b)(26)
87555 General Food Service Requirements (b) The following food service requirements shall apply (26) Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises. This requirement is not met as evidenced by:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview the Licensee failed to provide sufficient 2-day supply of perishable food & a 7-day supply of non-perishable foods which is a potential health risk to residents in care.
POC Due Date: 04/20/2026
Plan of Correction
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The Administrator purchased two (2) days perishable and seven (7) days non-perishable food during today’s visit. POC cleared during today’s visit.
Type B
Section Cited
CCR
87412(a)(11)
Personnel records: (a)Th e licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11)A health screening as specified in Section 87411, Personnel Requirements - General.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review the Administrator and Staff #1 (S1) did not have Health screening form and TB test on file. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/20/2026
Plan of Correction
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2
3
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The Administrator agreed to update and retain a current health screening report, showing negative or positve test results for the Administrator and S2 by POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Nichelle Gillyard
NAME OF LICENSING PROGRAM MANAGER:
Huma Rahimi
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/13/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/13/2026


LIC809 (FAS) - (06/04)
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