<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405800577
Report Date: 06/18/2025
Date Signed: 06/18/2025 05:23:28 PM

Document Has Been Signed on 06/18/2025 05:23 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 N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:VILLAGE AT SYDNEY CREEK, THEFACILITY NUMBER:
405800577
ADMINISTRATOR/
DIRECTOR:		LIZA HIXFACILITY TYPE:
740
ADDRESS:1234 LAUREL LANETELEPHONE:
(805) 543-2350
CITY:SAN LUIS OBISPOSTATE: CAZIP CODE:
93401
CAPACITY: 84CENSUS: 54DATE:
06/18/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:35 AM
MET WITH:Administrator - Liza HixTIME VISIT/
INSPECTION COMPLETED:
05:30 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
 At 08:35am, on 06/18/2025, Licensing Program Analyst (LPA) Haner-Tomasko arrived at the facility unannounced to conduct the annual facility inspection. LPA met with Administrator Liza Hix, announced who he was and the reason for the visit.

Administrator and LPA conducted a full tour of the facility. This facility has a main entry with lobby accessible to the public and from the main lobby there is locked access to three units (neighborhoods). Neighborhood 1 and 2 connect via doors and garden area and neighborhood 3 has its own entry point and patio space. There are a total of 44 resident bedrooms that can be designated single or dual occupancy, but never allow the facility to exceed a census of 84. Each resident bedroom has a private bathroom and there are public bathrooms located in each neighborhood and the main lobby. Each neighborhood has a common space, dining area, kitchen for serving meals, and laundry space for urgent laundry needs. LPA noted the garden areas in each neighborhood have seating and shade, and are accessible freely to residents and visitors.

While touring the facility with the Administrator, the LPA noted multiple hazardous items not locked up, accessible to residents, and unattended. At 10:52am while touring the kitchen in neighborhood 2 LPA observed and photographed an aerosol can of Spray Scents deodorizer in the non-lockable cabinet to the right of the refrigerator, accessible to residents in care. At 10:56am, also in neighborhood 2's kitchen LPA observed and photographed 7 bottles of nail polish, a bottle of nail polish remover and an aerosol can of nail dryer in a kitchen cabinet under the bar counter that was missing the lock pieces giving access to residents.

(Continued on LIC809-C)

NAME OF LICENSING PROGRAM MANAGER: Kelly Burley
NAME OF LICENSING PROGRAM ANALYST: Garrett Haner-Tomasko
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 06/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/18/2025
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 4
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)
Page: 2 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: VILLAGE AT SYDNEY CREEK, THE
FACILITY NUMBER: 405800577
VISIT DATE: 06/18/2025
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
26
27
28
29
30
31
32
 At 11:19am while touring neighborhood 3's kitchen, LPA observed and photographed an aerosol can of Zep Freshen Disinfectant Spray in a non-locking cabinet between the refrigerator and oven accessible to residents in care. At 11:27am LPA observed and photographed a spray bottle of glass cleaner on the bathroom counter in bedroom 309, accessible to residents in care.

Off the main lobby and inaccessible to unattended residents are offices, conference rooms, access to the licensed adult day program, the main kitchen that prepares and delivers all meals to each neighborhood for serving, the medication room, a salon, wellness room, four public restrooms and a staff room. LPA observed at least 2-days of perishable and at least 7-days of nonperishable foods.

The facility has wired smoke detectors inspected on 8/21/2024 by Alpha Fire & Security Alarm. There is a carbon monoxide detector located in each neighborhood and main lobby. LPA observed fire extinguishers throughout the facility, tagged current and in the green compression range, serviced on 06/28/2024. LPA noted the facility boilers for hot water delivery to all facility faucets were being repaired at the time of the visit.

LPA conducted a sample medication audit and reviewed the facilities Centrally Stored Medication Records, finding no violations.

LPA was not able to complete the annual inspection and may return at a later time to finish.

Pursuant to Title 22, California Code of Regulations, the following deficiency is cited (refer to LIC809-D).


Exit interview conducted, appeal rights and a copy of this report issued.
NAME OF LICENSING PROGRAM MANAGER: Kelly Burley
NAME OF LICENSING PROGRAM ANALYST: Garrett Haner-Tomasko
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2025
LIC809 (FAS) - (06/04)
Page: 4 of 4
Document Has Been Signed on 06/18/2025 05:23 PM - It Cannot Be Edited


Created By: Garrett Haner-Tomasko On 06/18/2025 at 04:31 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. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: VILLAGE AT SYDNEY CREEK, THE
FACILITY NUMBER: 405800577

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/18/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space and Access
(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and interview, the licensee did not comply with the section cited above when an aerosol can of Spray Scents deodorizer, 7 bottles of nail polish, a bottle of nail polish remover, an aerosol can of nail dryer, an aerosol can of Zep Freshen Disinfectant Spray and a spray bottle of glass cleaner were left unattedned and accessible to residents in care which poses an immediate health, safety and personal rights risk to persons in care.
POC Due Date: 06/19/2025
Plan of Correction
1
2
3
4
Administrator Liza Hix and Vice President of Operations Lisa Hulse agree to create an information sheet regarding the cited regulation and company policy regarding the regulation on or before 6/19/2025. The info sheet will be provided to all staff via there facility mailbox and LPA via email on 6/19/2025. Additionally they will conduct training with all staff on this regulation and email LPA documentation of this training and signed staff roster on or before 7/2/2025.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Kelly Burley
NAME OF LICENSING PROGRAM MANAGER:
Garrett Haner-Tomasko
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/18/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/18/2025


LIC809 (FAS) - (06/04)
Page: 3 of 4