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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610706
Report Date: 05/02/2025
Date Signed: 05/02/2025 02:23:25 PM

Document Has Been Signed on 05/02/2025 02:23 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:AZALEA HOUSEFACILITY NUMBER:
197610706
ADMINISTRATOR/
DIRECTOR:		HEWITT, AMBERFACILITY TYPE:
740
ADDRESS:1952 MAIDEN LANETELEPHONE:
(626) 239-9051
CITY:ALTADENASTATE: CAZIP CODE:
91001
CAPACITY: 6CENSUS: 0DATE:
05/02/2025
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:45 AM
MET WITH:Administrator, Amber HewittTIME VISIT/
INSPECTION COMPLETED:
02:40 PM
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At 9:40a.m., Licensing Program Analyst (LPA), Antonia Alvizar-Ettima conducted an announced Pre-Licensing visit to the above facility and met with Administrator. An Application to operate a Residential Care Facility for the Elderly (RCFE) was received by Community Care Licensing (CCL).

Fire Clearance was approved on 12/04/2024 for a maximum capacity of six (6) non-ambulatory residents, hospice waiver for two (2) residents age range 60 and over. The purpose of today’s visit is to inspect the facility to ensure that the physical plant is in compliance with rules and regulations of California Code of Regulations, Title 22, Division 6, Chapter 8. The facility is a single-story building in a residential community. The facility has two (2) fully charged fire extinguishers, locate in the entryway and laundry room. Fire extinguishers receipt dated May 02, 2025.

A tour of the physical plant inside and outside was initiated at approximately 10:10a.m., and the following was observed: KITCHEN: The facility has a kitchen area that is equipped with a refrigerator, dish washer, sink, stove and microwave. There were adequate supplies of perishable and nonperishable food and dining ware to accommodate a maximum capacity of six (6) residents. All knives and sharps are observed to be locked in a drawer in the kitchen and inaccessible to residents. LAUNDRY ROOM: The laundry room is located adjacent to the kitchen. The washer/dryer are new. Laundry supplies are kept inaccessible when not in use in a locked cabinet. BEDROOMS: There are four (4) bedrooms designated for residents to use. Bedroom #1-#2 are shared rooms, bedrooms #3-#4 are private rooms. All resident bedrooms are furnished with bed, chair, nightstand, dresser and required bedding and linen.

Continue on LIC809-C

NAME OF LICENSING PROGRAM MANAGER: Naira Margaryan
NAME OF LICENSING PROGRAM ANALYST: Antonia Alvizar-Ettima
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/02/2025
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: AZALEA HOUSE
FACILITY NUMBER: 197610706
VISIT DATE: 05/02/2025
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Cont. from LIC 809

The bedrooms have sufficient closet space and have sufficient lighting. BATHROOMS: LPA inspected the bathrooms they are clean and in excellent condition. LPA observed three (3) bathrooms with grab bar and non-skid mats for residents and staff to use. Water temperature was within regulation ranging between 110.9°F – 116.1°F. LPA also observed sufficient quantity of toilet papers, soap and paper towels. COMMON AREAS: The facility maintains a comfortable temperature at 74°F. The living room has a television, recliner, couches, books, board games and magazines. The dining area has a table with six (6) chairs that were clean and properly furnished. MEDICATION: The medication and first aid kit will be kept in kitchen cabinet. All medication will be locked inaccessible to residents. The facility staff/resident files will be kept in a locked kitchen cabinet, inaccessible to residents. SMOKE DETECTORS/CARBON MONOXIDE: Four (4) smoke detectors were located in the bedrooms and throughout the facility. All smoke deters were dual carbon monoxide. They were tested and observed to be operational. SURROUNDING GROUNDS: The facility grounds were well landscaped and enclosed. The passageways and entrance to the facility were clear of obstruction. Entry and exit doors have a functional auditory alert when the doors open. There is an approved Accessory Dwelling Unit (ADU) on the left side of the facility. LPA observed appropriate outdoor furniture and sufficient yard for residents. LPA discussed the importance of maintaining the care and supervision to meet the needs of residents. The facility has no bodies of water.

Component III: Administrator, Amber Hewitt completed the Component III during today’s Pre-Licensing visit.

Based on inspection and observation, the physical plant is in compliance with Title 22 Regulations at this time. This report will be forwarded to the Centralized Application Bureau (CAB) and the applicant will be notified by the CAB Analyst when your license has been approved.

Exit interview was conducted and a copy of this report was provided to Administrator.

NAME OF LICENSING PROGRAM MANAGER: Naira Margaryan
NAME OF LICENSING PROGRAM ANALYST: Antonia Alvizar-Ettima
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/02/2025
LIC809 (FAS) - (06/04)
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