197610882-10-30-2025-31-AS-JGTN-DMXQ6L-20251030115342

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610882
Report Date: 10/30/2025
Date Signed: 10/30/2025 11:54:05 AM

Document Has Been Signed on 10/30/2025 11:54 AM - 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:	AFFORDABLE BOARD AND CARE INC II		FACILITY NUMBER:	197610882
ADMINISTRATOR/ DIRECTOR:	KESHISHI, VILBERT		FACILITY TYPE:	740
ADDRESS:	11314 HUNNEWELL AVE LAKEVIEW		TELEPHONE:	(818) 397-5690
CITY:	LAKEVIEW TERRACE	STATE: CA	ZIP CODE:	91342
CAPACITY: 6		CENSUS: 0	DATE:	10/30/2025
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:52 AM
MET WITH:	Vilbert Keshishi - Licensee Representative		TIME VISIT/ INSPECTION COMPLETED:	12:00 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	Licensing Program Analyst (LPA) Jose Tan conducted an announced Pre Licensing visit to this facility and met with applicant representative Vilbert Keshishi. The applicant is "Affordable Board and Care II Inc". Fire Clearance dated 09/08/25 was received for six (6) non-ambulatory residents, one (1) of which may be bedridden on room #1. Purpose of today’s visit is to inspect the facility to ensure that the facility is in compliance with the rules and regulations of California Code of Regulations, Title 22, Division 6. Facility is a single storey home. Today's site visit consisted of LPA touring the physical plant inside and outside and observed the following: The facility dual smoke/carbon monoxide alarm system is hard wired and interconnected. The fire extinguisher is located in the kitchen and was observed to be fully charged and last bought on 09/05/2025. Dual Smoke and Carbon Monoxide detectors were observed all over the facility, tested and observed to be operational. Hot water was tested in the common bathrooms and was told that the gas is not yet on service so there is no hot water at the facility at this time. The telephone on the premises is not yet functional. An emergency exit plan/sketch is posted on the hallway wall with other posting requirements. There are three (3) resident bedrooms, all shared. There is one (1) additional bedroom and bathroom designated for staff use. Resident bedrooms were observed to be appropriately furnished. The common areas (living room, kitchen and dining areas) were not yet furnished during this visit. Lighting was adequate. Resident and staff records will be stored in a locked kitchen cabinet. Medications will also be stored in the same locked cabinet. (continued on LIC 809-C)

NAME OF LICENSING PROGRAM MANAGER: Troy Agard
NAME OF LICENSING PROGRAM ANALYST: Jose Gary Tan
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 10/30/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2025

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: AFFORDABLE BOARD AND CARE INC II	FACILITY NUMBER: 197610882
	VISIT DATE: 10/30/2025

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(continued from LIC 809)

The first aid kit is readily available. There are two (2) bathrooms in the facility. The common bathroom has non-skid mat and appropriate grab bars installed.

The kitchen knives are stored in a locked drawer in the kitchen. Kitchen cleaning supplies will be stored in a locked shed located in the backyard. There is no laundry machine and dryer installed during this visit. Laundry detergents, cleaning supplies and other toxins will be stored in the laundry area. The laundry area is located adjacent to the kitchen. The necessary precautions have been made to the facility to safely house dementia residents such as auditory alarms on all doors and locked areas for centrally stored medications. Facility appears to be clean and in good repair. Appliances in the kitchen appeared to be functional.

There is a sitting area in the backyard for residents to conduct outdoor activities. The backyard is fenced. The garage was converted as an additional dwelling unit (ADU) with a separate address. There is no body of water in the facility.

Component III was not done during this visit.

Facility is not in compliance with Title 22 Regulations at this time. The licensee representative was informed that the LPA will come back another day when all the needed correction are done.

Exit interview conducted. Copy of this report issued.

NAME OF LICENSING PROGRAM MANAGER: Troy Agard
NAME OF LICENSING PROGRAM ANALYST: Jose Gary Tan
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 10/30/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2025

LIC809 (FAS) - (06/04)

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