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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610819
Report Date: 10/17/2025
Date Signed: 10/17/2025 02:14:50 PM

Document Has Been Signed on 10/17/2025 02:14 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:4 ACES ELDERLY CAREFACILITY NUMBER:
197610819
ADMINISTRATOR/
DIRECTOR:		REYES, MARICELFACILITY TYPE:
740
ADDRESS:3920 COBBLE COURTTELEPHONE:
(661) 350-2232
CITY:PALMDALESTATE: CAZIP CODE:
93551
CAPACITY: 6CENSUS: 0DATE:
10/17/2025
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Maricel ReyesTIME VISIT/
INSPECTION COMPLETED:
11:30 AM
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On 10/17/2025 Licensing Program Analyst (LPA) Melissa Spaeth conducted an announced pre-licensing visit to this facility and met with the Applicant, Maricel Reyes. This is a new application. A fire clearance dated 09/23/2025 was received for five (5) non-ambulatory residents and one (1) bedridden of which bedroom one to house one non-ambulatory resident, Room 2 for staff only, Room 3 to house one non-ambulatory and one bedridden resident, Room 4 to house one non-ambulatory resident, and room 5 to house two non-ambulatory residents.

The purpose of today’s visit is to inspect the facility to ensure that it maintains compliance under California Code of Regulations, Title 22, Division 6. Component III was conducted with the applicant from 9:30 am 10:00 am.

LPA and the Licensee toured the physical plant inside and outside from 10:00 am until 10:30 am. LPA Spaeth observed the following:

Living Room-LPA observed comfortable seating.

Family Room - LPA observed comfortable seating and television.

Kitchen- The kitchen contained a dining room table and chairs. The knives were locked underneath the kitchen sink. The staff files, resident files, first aid kit, and medications are locked in the kitchen. The facility contained a two-day supply of perishable food and a seven day supply of non-perishable food. A fire extinguisher is located in the kitchen.

Continued on 809-C

NAME OF LICENSING PROGRAM MANAGER: Troy Agard
NAME OF LICENSING PROGRAM ANALYST: Melissa Spaeth
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 10/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/17/2025
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.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: 4 ACES ELDERLY CARE
FACILITY NUMBER: 197610819
VISIT DATE: 10/17/2025
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Laundry Room – The room contained a washer and dryer. A locked door lead to the garage.

Garage – the garage was locked and contained a locked cabinet which is the storage location for the cleaning supplies.

Backyard - The backyard has a shaded area with a table and chairs. The gate leading from the back yard to the front yard was not locked.

Water Temperature - The water temperature was tested at 10:15 am and was 111 degrees F.

Bathrooms- The bathrooms contained hand soap, slip resistant mats, paper towels, grab bars and a trash can.

Bedrooms – The bedrooms contained bed, linens, night stand, chest of drawers, a chair, and a closet.

Staff Room - The staff room contained a bed and was locked.

Hallway Closet - The hallway closet contained linens.

Egress - All exits doors contain the delayed egress alarms and were all operable.

The smoke/carbon monoxide detectors were tested at 11:20 am and were operable. The facility was clean and appears to be in good repair.

This report will be forwarded to the Centralized Application Bureau (CAB). You will be notified by the CAB Analyst when your license has been approved.

NAME OF LICENSING PROGRAM MANAGER: Troy Agard
NAME OF LICENSING PROGRAM ANALYST: Melissa Spaeth
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2025
LIC809 (FAS) - (06/04)
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