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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610682
Report Date: 06/27/2025
Date Signed: 06/27/2025 03:47:47 PM

Document Has Been Signed on 06/27/2025 03:47 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:MAGNOLIA HOME, THEFACILITY NUMBER:
197610682
ADMINISTRATOR/
DIRECTOR:		KAUR, UKARJITFACILITY TYPE:
740
ADDRESS:6707 SAUSALITO AVETELEPHONE:
(661) 236-6787
CITY:WEST HILLSSTATE: CAZIP CODE:
91307
CAPACITY: 5CENSUS: 0DATE:
06/27/2025
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:Ukarjit Kaur and Celena ShermanTIME VISIT/
INSPECTION COMPLETED:
04:00 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
At 1:00 p.m. on 06/27/25 Licensing Program Analyst (LPA) Nicholas Reed conducted an announced prelicensing inspection. LPA met with applicants Ukarjit Kaur and Celena Sherman and disclosed the reason for the visit.

Today’s prelicensing inspection is an initial application with no residents in care. The facility is a single story building with three (03) bedrooms, three (03) bathrooms, office, kitchen, common areas, and outdoor areas. There are two (02) additional dwelling units (ADUs) near the property which are appropriately separated from the main property to provide security and confidentiality for all residents. Neither ADU has access to the facility. The facility has an approved fire clearance for five (05) non-ambulatory residents, of which one (01) may be bedridden in Bedroom #3. The facility intends to serve residents with dementia.

The front yard was maintained and free of hazards. At the main entrance, LPA observed postings for COVID precautions, personal rights, rights of resident councils, theft and loss policy, facility sketch, and confidential complaint contacts. Walls, floors, windows, screens, and blinds were clean and in good repair. At 1:10 p.m. LPA measured the room temperature to be 72 degrees Fahrenheit. Activities, board games, a television, furniture in good repair, and art supplies were available in the living room. At approximately 1:15 p.m., LPA observed a fully charged fire extinguisher near the kitchen. It was last inspected on 03/24/25 and had a tag attached. At 1:20 p.m. five (05) out of five (05) auditory alarms were tested and operational. A hallway closet contained hygiene supplies, paper supplies, and an adequate supply of fresh linens. At 1:30 p.m. the smoke and carbon monoxide detectors were tested and deemed operational. Smoke detectors were hard-wired and operated simultaneously when tested. Two (02) out of two (02) fire doors also closed appropriately when tested. At 1:40 p.m., the house telephone was called and deemed operational.

NAME OF LICENSING PROGRAM MANAGER: Naira Margaryan
NAME OF LICENSING PROGRAM ANALYST: Nicholas Reed
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 06/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/27/2025
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 3
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 3
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: MAGNOLIA HOME, THE
FACILITY NUMBER: 197610682
VISIT DATE: 06/27/2025
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
LPA observed an adequate supply of non-perishable foods pantry. The stove hood was clean. Appliances were in good condition. The refrigerator and freezer temperatures were measured to be forty (40) and zero (00) degrees, respectively. Sharps were locked below the counter. Cleaning solutions were locked below the sink. Medications and a complete first aid kit were locked in a kitchen cabinet. A laundry area near the kitchen contained a washing machine and dryer. Both were in working order.

The facility has three (03) bedrooms. Two (02) bedrooms are shared and one (01) is private. All bedrooms contained a chair, lighting, nightstand, closet storage, and a bed with adequate bedding. All furnishings were clean and in good condition. The office area had paper supplies and a computer.

The facility has three (03) bathrooms. Two (02) bathrooms are private, and one (01) is shared. Resident bathrooms contained liquid soap, paper towels, trash cans with a tight fitting lid, grab bars near the toilet and shower, and a non-skid mat in the shower. A commode was available as well. At approximately 1:50 p.m. LPA measured the water temperature in the bathroom in Bedroom #2 to be 119.0 degrees Fahrenheit.

Outdoor areas were maintained and contained fruit-bearing trees and gardened areas. A jacuzzi was observed with a 4-point locking system employed. The jacuzzi was also drained, so it was not considered a hazardous body of water. The patio contained furniture in good condition with adequate shade. Ramps leading out were secure. The emergency exit path was free from obstructions. The northern exit gate was unlocked.

Pre-Licensing is complete and this facility has no deficiencies.

Exit interview conducted. Copy of report provided.

NAME OF LICENSING PROGRAM MANAGER: Naira Margaryan
NAME OF LICENSING PROGRAM ANALYST: Nicholas Reed
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/27/2025
LIC809 (FAS) - (06/04)
Page: 3 of 3