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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405800987
Report Date: 08/12/2025
Date Signed: 08/12/2025 03:05:45 PM

Document Has Been Signed on 08/12/2025 03:05 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:IRENE'S BOARD & CAREFACILITY NUMBER:
405800987
ADMINISTRATOR/
DIRECTOR:		ANGELITA O. MARAVILLASFACILITY TYPE:
740
ADDRESS:220 VIA PROMESATELEPHONE:
(805) 227-0276
CITY:PASO ROBLESSTATE: CAZIP CODE:
93446
CAPACITY: 6CENSUS: 5DATE:
08/12/2025
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:28 AM
MET WITH:Lead Staff - Kevin SchaeferTIME VISIT/
INSPECTION COMPLETED:
02:15 PM
NARRATIVE
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At 9:28am, on 8/12/2025, Licensing Program Analyst (LPA) Haner-Tomasko conducted an unannounced Case Management - Legal/Non-Compliance visit. The purpose of today’s visit was to ensure the facility is maintaining substantial compliance as discussed in the Non-Compliance Conference that took place on 07/01/2025. As a result of the non-compliance conference, the licensee is placed on frequent monitoring for a period of two years. LPA met with Lead Staff Kevin Schaefer and explained the reason for the visit. The LPA focused today’s visit on ensuring there are no health and safety hazards, and the facility is in compliance with Title 22 Regulations.

At 9:35am, LPA and Lead Staff Kevin Schaefer conducted a walk through of the facilities first floor where residents reside, the second floor is only accessed by facility staff. LPA observed four (4) residents were in chairs in the family room watching TV and the fifth resident was in bed in their room. Resident rooms were observed to be furnished appropriately with sufficient lighting. Resident bathrooms were sufficiently stocked with supplies and paper towels. At 9:48am LPA observed an aerosol can of Raid bug spray and a can of Pledge furniture cleaner sitting out on bookshelves in the family room accessible to residents and at 9:52am an aerosol can of Favor furniture cleaner and Clorox disinfectant mist left out in the living room next to the TV accessible to residents in care. This facility fire clearance allows for a bedridden resident in bedroom #3. LPA interview revealed Resident #1 (R1) requires assistance from staff with turning or repositioning, meaning R1 meets the bedridden definition in Title 22 Regulations for this facility type and R1 does not reside in bedroom #3. The facility has battery operated smoke detectors in each bedroom and the hallway leading to bedrooms that are all working, the carbon monoxide detector is in the hallway and functioning normally.

(Continued on LIC809-C)

NAME OF LICENSING PROGRAM MANAGER: Kelly Burley
NAME OF LICENSING PROGRAM ANALYST: Garrett Haner-Tomasko
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 08/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/12/2025
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 5
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 N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: IRENE'S BOARD & CARE
FACILITY NUMBER: 405800987
VISIT DATE: 08/12/2025
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LPA observed multiple fire extinguishers throughout the facility in the green compression range, Kevin stated none of them have been serviced or purchased in the last year. Fire clearance violations were cited. At 10:16am LPA tested facility hot water in the resident shower which reached a maximum of 97.9*(f), not within regulation temperatures of 105*-120*(f). LPA observed at least 2-days of perishable and at least 7-days of nonperishable foods. LPA noted a previous deficiency on 11/18/2024 when the Licensee was unable to show documentation of emergency drills conducted. The Licensee submitted documentation clearing the plan of correction for that deficiency on 12/04/2024. As of todays visit staff interview revealed an emergency drill has not been conducted this year.

LPA spoke with the Licensee over the phone as they could not be at the facility in person. Exit interview, deficiencies cited on LIC809-D pages, a civil penalty in the amount of $500 for fire clearance violations is being assessed on the LIC421IM, a civil penalty in the amount of $250 for a repeat violation is being assessed on the LIC421FC, report signed, report and appeal rights provided to Backup Administrator.

NAME OF LICENSING PROGRAM MANAGER: Kelly Burley
NAME OF LICENSING PROGRAM ANALYST: Garrett Haner-Tomasko
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2025
LIC809 (FAS) - (06/04)
Page: 5 of 5
Document Has Been Signed on 08/12/2025 03:05 PM - It Cannot Be Edited


Created By: Garrett Haner-Tomasko On 08/12/2025 at 12:19 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: IRENE'S BOARD & CARE
FACILITY NUMBER: 405800987

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/12/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/13/2025
Section Cited
CCR
87202(a)(2)

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Fire Clearance(a)...Prior to...retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city,...fire department,...or the State Fire Marshal. (2)Bedridden persons. This requirement was not met as
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Licensee will submit an LIC200, LIC9054, and the facility sketch to the LPA by 8/13/2025 to see if the fire marshal will update the fire clearance to meet the needs of the resident in care. Provide LPA with proof of fire extinguisher service or purchase by 8/26/2025.
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evidenced by: Based on observation and interview, the licensee did not follow their fire clearance a bedridden resident, R1, resides in a non bedridden room and fire extinguisher not serviced annually which poses an immediate Health and Safety risk to persons in care.
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Type A
08/13/2025
Section Cited
CCR87309(a)

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Storage Space and Access (a) ...the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances,... 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.
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Backup Administrator removed and locked up the items at time of LPA observation. Licensee will email LPA a statement of understanding on this regulation by 8/13/2025. Licensee will conduct staff training on this regulation and email LPA documentation of the
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This requirement was not met as evidenced by: Based on observation, the licensee did not follow this regulation when they left bug spray and cleaning solutions out and accessible to residents in care which poses an immediate Health and Safety risk to persons in care.
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training on or before 8/26/2025.
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: 08/12/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/12/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/12/2025 03:05 PM - It Cannot Be Edited


Created By: Garrett Haner-Tomasko On 08/12/2025 at 12:56 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: IRENE'S BOARD & CARE
FACILITY NUMBER: 405800987

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/12/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/26/2025
Section Cited
HSC
1569.695(c)

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(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. ...
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Licensee will conduct an emergency disaster drill on each shift and show proof to LPA by 08/26/2025 via email. Licensee will also create a written plan to ensure the required drills are conducted quarterly and email the plan to LPA on or before 8/26/2025.
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This requirement is not met as evidenced by: Based on interview and not being able to produce evidence of quarterly drills, the licensee did not comply with the section cited above during the facility visit which poses a potential health, safety or personal rights risk to persons in care.
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Type B
08/26/2025
Section Cited
CCR87303(e)(2)

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(e) Water supplies and plumbing fixtures shall be maintained as follows:(2)...Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F...
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Licensee will adjust water heater to meet the regulation and create a written plan to ensure the water temperature at all resident used faucets deliver water within regulation. Licensee will email the plan to LPA on or before 8/26/2025.
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This requirement is not met as evidenced by: Based on observation the licensee did not meet this regulation when LPA tested the resident shower temp reaching a maximum of 97.9 degree F which poses a potential 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.
Kelly Burley
NAME OF LICENSING PROGRAM MANAGER:
Garrett Haner-Tomasko
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/12/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/12/2025


LIC809 (FAS) - (06/04)
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