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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610651
Report Date: 09/30/2025
Date Signed: 09/30/2025 01:39:17 PM

Document Has Been Signed on 09/30/2025 01:39 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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:ST. PAUL RCFEFACILITY NUMBER:
197610651
ADMINISTRATOR/
DIRECTOR:		OBTINALLA, ARNIDAFACILITY TYPE:
740
ADDRESS:22235 WYANDOTTE STREETTELEPHONE:
(818) 448-2967
CITY:CANOGA PARKSTATE: CAZIP CODE:
91303
CAPACITY: 6CENSUS: 4DATE:
09/30/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:30 AM
MET WITH:Arnida Obtinalla, AdministratorTIME VISIT/
INSPECTION COMPLETED:
01:30 PM
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At 11:30am, Licensing Program Analyst (LPA) Angela Panushkina arrived at the facility to conduct an annual inspection. LPA met with the Administrator and explained the reason for the visit.

A tour of the physical plant was initiated at 11:35am and the following was observed:

The facility is cleared for six (6) Non-Ambulatory residents and a hospice waiver/granted for four (4).

Kitchen: The kitchen area is equipped with a refrigerator, microwave oven and sink. LPA observed there to be sufficient stock of perishable and non-perishable foods. Frozen foods are properly wrapped and stored appropriately. Food storage and preparation areas are clean and inaccessible to pests. All knives were observed to be locked in the kitchen drawer. The fire extinguisher was purchased on 12/03/2024. Medications and resident/staff files are kept in locked cabinet, in the kitchen. There is a complete first-aid kit it with all required supplies and with the first aid manual.

Bedrooms: The facility has a total of six (6) bedrooms, five (5) of which are designated for residents use, one (1) room is designated for live-in staff. The bedrooms are appropriately furnished with sufficient closet space and have sufficient lighting. All exit doors will have an auditory alarm.

Bathrooms: Facility has three (3) bathrooms. Bathrooms have soap, paper towels and all trash cans have a lid. Extra towels and linens were readily available. The hot water temperature measured at 114.1°F. The facility maintains a comfortable temperature of 76°F. LPA observed all common areas are furnished with adequate furniture to accommodate a maximum capacity of six (6) residents. There is a functioning telephone on the premises. Continue on LIC809-C

NAME OF LICENSING PROGRAM MANAGER: Nichelle Gillyard
NAME OF LICENSING PROGRAM ANALYST: Angela Panushkina
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/30/2025
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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: ST. PAUL RCFE
FACILITY NUMBER: 197610651
VISIT DATE: 09/30/2025
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Smoke detectors carbon monoxide is located throughout the facility and at 12:00pm they were tested and observed to be operational.

Laundry Room: The laundry is located by the office/kitchen area. The washer/dryer appears to be in good condition. Laundry supplies are kept inaccessible when not in use with supervision.

Outside Areas: The back of the facility has sufficient yard space. At 12:30pm, LPA observed appropriate outdoor furniture, with a covered shaded area for the residents. The outdoor area is free of visible immediate hazards. LPA discussed the importance of maintaining the care and supervision to meet the needs of residents. There are no bodies of water.

Between 12:40pm to 1:20pm, LPA reviewed records of six (6) residents and three (3) staff. Resident and staff records appeared to be complete and updated. Resident’s files contain signed admission agreements and a medical assessment, and all other required documentation.

LPA observed Administrator certificated renewed on 05/08/2024 with an expiration date of 05/07/2026. LPA collected Certificate of Liability Insurance and LIC500.

No citations issued during this visit.

Exit interview conducted and copy of this report signed and delivered.

NAME OF LICENSING PROGRAM MANAGER: Nichelle Gillyard
NAME OF LICENSING PROGRAM ANALYST: Angela Panushkina
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2025
LIC809 (FAS) - (06/04)
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