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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610840
Report Date: 12/18/2025
Date Signed: 12/18/2025 03:23:58 PM

Document Has Been Signed on 12/18/2025 03:23 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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:PRINCE'CESS ELDER CAREFACILITY NUMBER:
197610840
ADMINISTRATOR/
DIRECTOR:		PO, VALIANTFACILITY TYPE:
740
ADDRESS:10055 SUNNYBRAE AVETELEPHONE:
(747) 202-3623
CITY:CHATSWORTHSTATE: CAZIP CODE:
91311
CAPACITY: 6CENSUS: 4DATE:
12/18/2025
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:30 PM
MET WITH:Viliant Po, Administrator TIME VISIT/
INSPECTION COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) Angela Panushkina conducted a Pre-Licensing Inspection and met with the Applicant, Valiant Po. This is a Change of Ownership Application from facility #197610091 to #197610840. An application to operate Residential Care Facility for the Elderly was received by Community Care Licensing (CCL) on 06/12/2025. A fire clearance was approved on 09/04/2025 for a maximum capacity of six (6) residents, of which five (5) Non-ambulatory and one (1) Bedridden (in bedroom #5)

A tour of the physical plant was initiated at 12:40pm and the following were observed:

The facility is a single-story home consisting of four (4) bedrooms, designated for residents’ use only, and two and a half (2½ ) bathrooms. Room #2 is designated for live-in staff use only. LPA observed that all bedrooms are furnished with beds, dressers and required bedding and linen. The bedrooms have sufficient closet space and have sufficient lighting. Facility maintains a temperature of 70°F.

LPA observed all bathrooms are clean and in good repair. All bathrooms have a working toilet, wash basin and a shower. Properly supplied with toilet paper, soap and paper towels. At 12:55pm, the hot water temperature measured at 116.7°F. All trash cans in bathrooms had fitted lids to protect them from cross contamination.

The kitchen area is equipped with a refrigerator, microwave oven and sink. There were adequate supplies of perishable and nonperishable foods and dining wares to accommodate a maximum capacity of six (6). There is a fire extinguisher in the kitchen area and was last serviced on 08/11/2025.

Continue on LIC809-C

NAME OF LICENSING PROGRAM MANAGER: Nichelle Gillyard
NAME OF LICENSING PROGRAM ANALYST: Angela Panushkina
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 12/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/18/2025
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)
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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: PRINCE'CESS ELDER CARE
FACILITY NUMBER: 197610840
VISIT DATE: 12/18/2025
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The medications are kept in a locked cabinet/drawer located by the kitchen area. Resident and staff files were observed in a locked metal cabinet located in the dining area. The first-aid kit has been inspected which has at least the following: tweezers, scissors, antiseptic, bandages, gauze, thermometer; including a current First Aid manual.

The Common areas are furnished with adequate furniture to accommodate a maximum capacity of six residents. At 1:00pm, smoke and carbon monoxide detectors were tested and observed to be operable. There were no visible immediate hazards.

The laundry room is located in the garage. The washer/dryer appears to be in good condition. Laundry supplies are kept inaccessible when not in use with supervision.

At 1:10pm, LPA toured the outside area of the facility. LPA observed appropriate outdoor furniture, with a covered shaded area for residents. The outdoor area was free of visible immediate hazards. LPA discussed the importance of maintaining care and supervision to meet the needs of residents.

Smoke detectors and carbon monoxide were tested at 1:15pm and observed to be functional.

Between 1:20pm to 2:20pm, LPA reviewed records of four (4) residents and two (2) 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 documentarians.

Component III was conducted at 2:30pm.

Pursuant to Title 22, Division 6 Chapter 2, the facility's physical environment appears to be compliant and ready for licensure. CAB will be advised, and a copy of this report will be emailed.

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: 12/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/18/2025
LIC809 (FAS) - (06/04)
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