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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610739
Report Date: 04/22/2026
Date Signed: 04/22/2026 03:55:37 PM

Document Has Been Signed on 04/22/2026 03:55 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:PLATINUM CROWN INCFACILITY NUMBER:
197610739
ADMINISTRATOR/
DIRECTOR:		ALEKSANI, TAMARAFACILITY TYPE:
740
ADDRESS:20535 ENADIA WAYTELEPHONE:
(818) 740-1298
CITY:WINNETKASTATE: CAZIP CODE:
91306
CAPACITY: 6CENSUS: 6DATE:
04/22/2026
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:30 AM
MET WITH:ALEKSANI, TAMARA- administratorTIME VISIT/
INSPECTION COMPLETED:
04:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Leslie Ngo-Castaneda conducted unannounced initial visit to this facility in conjunction with a complaint control #31-AS-20260417141106. LPA met with Staff #2 (S2) Behrouz Atri, who granted access to facility. S2 is not associated with facility, immediate civil penalty will be issued in LIC 421BG.

During physical plant tour, the following was observed:
  • LPA observed in bedroom #2, R6 having a pocket knife beside his bed on the floor, who shared a room with a dementia resident.
  • S2 was observe using bedroom #3 without knocking to enter and access the patio.
  • Per S2 they have been working at the facility has been working since December 2025. LPA review background clearance is cleared but not associated with the facility.

During record review, the following was observed:
  • R6 not having a file at the facility, they have been residing at the facility for more than 2 weeks.
  • R1 not having medication at the facility.
  • S1 and S2 not having files at the facility.


Exit interview conducted, Citations issued, Appeal rights given and a copy of this report delivered.
NAME OF LICENSING PROGRAM MANAGER: Mary G Flores
NAME OF LICENSING PROGRAM ANALYST: Leslie Ngo-Castaneda
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/22/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/22/2026
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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Document Has Been Signed on 04/22/2026 03:55 PM - It Cannot Be Edited


Created By: Leslie Ngo-Castaneda On 04/22/2026 at 12:17 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: PLATINUM CROWN INC
FACILITY NUMBER: 197610739

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/22/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/23/2026
Section Cited
CCR
87355(e)(3)

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The licensee shall submit these fingerprints to the California Department of Justice, along with a second set of fingerprints for the purpose of searching the records of the Federal Bureau of Investigation, or comply with Section 87355(c), prior to the individual's employment, residence, or initial
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Administrator has agreed to complete Guardian association of S2 to facility by POC due date.
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presence in the facility.This requirement is not met as evidence by: Based on interview and review of Guardian Background System Check facility Staff S2 is criminal background is clearanced but not associated to the facility. This poses a potential risk to residents in care.
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Type A
04/23/2026
Section Cited
CCR87309(a)

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The licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, ...which could pose a danger to residents are in locked storage and are This requirement is not met as evidenced by:
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Administrator locked away R6 knife.
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not left unattended if outside the locked storage. Based on LPA's observations, staff did not comply with the section cited above. LPA observed R6 pocket knife were not locked in a cabinet which poses an immediate health, safety or personal rights risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Mary G Flores
NAME OF LICENSING PROGRAM MANAGER:
Leslie Ngo-Castaneda
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/22/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/22/2026


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 04/22/2026 03:55 PM - It Cannot Be Edited


Created By: Leslie Ngo-Castaneda On 04/22/2026 at 12:45 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: PLATINUM CROWN INC
FACILITY NUMBER: 197610739

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/22/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/06/2026
Section Cited
CCR
87468.2(A)(1)

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To have a reasonable level of personal privacy in accommodations, medical treatment, personal care and assistance, visits, communications, telephone conversations, use of the Internet, and meetings of resident and family groups.
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Administrator will write a plan to LPA acknoledging a correction for deficiency BY POC date.
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This requirement was not met as evidenced by: LPA observe S2 entering bedroom #3 without knockling to access the patio as a passageway.
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Type B
05/06/2026
Section Cited
CCR87506(a)

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Prior to, or within two weeks of the resident’s admission, the licensee shall arrange a meeting with the resident,... of the resident’s home health agency, if any, and any other. appropriate parties, to prepare a writtenrecord of the care the resident will receive in
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Administrator will create a file for R6.
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the facility, and the resident’s preferences regarding the services provided at the facility. This requirement is not met as evidenced by: R6 does not have a file at the facility, which poses an immediate health, safety or personal rights risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Mary G Flores
NAME OF LICENSING PROGRAM MANAGER:
Leslie Ngo-Castaneda
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/22/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/22/2026


LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 04/22/2026 03:55 PM - It Cannot Be Edited


Created By: Leslie Ngo-Castaneda On 04/22/2026 at 02:54 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: PLATINUM CROWN INC
FACILITY NUMBER: 197610739

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/22/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/06/2026
Section Cited
CCR
87464(F)(6)

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Arrangements to meet health needs, including arranging transportation, as specified in Section 87465, Incidental Medical and Dental Care Services.
This requirement was not met as evidenced by:
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Administrator agreed to pick-up R1 medication immediately.
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LPA observe R1 did not have any medications at the facility.
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Type B
05/06/2026
Section Cited
CCR87412(a)

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The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. This requirement is not met as evidenced by: No files were available for LPA to review for S1 and S2.
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Administrator agrees to create and retain S1 and S2 file at the facility by POC date.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Mary G Flores
NAME OF LICENSING PROGRAM MANAGER:
Leslie Ngo-Castaneda
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/22/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/22/2026


LIC809 (FAS) - (06/04)
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