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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405800987
Report Date: 12/12/2025
Date Signed: 12/12/2025 02:17:21 PM

Document Has Been Signed on 12/12/2025 02:17 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: 4DATE:
12/12/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:20 AM
MET WITH:Licensee Angelita MaravillasTIME VISIT/
INSPECTION COMPLETED:
02:40 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 9:20am, on 12/12/2025, Licensing Program Analyst (LPA) Haner-Tomasko arrived at the facility unannounced to conduct the annual facility inspection. LPA met with Licensee/Administrator Angelita Maravillas, announced who he was and the reason for the visit.

Licensee and LPA conducted a full tour of the facility. This facility is a two story residential home. LPA noted only staff have access to the second floor where there are live-in staff bedrooms and bathrooms; all resident bedrooms and bathrooms are on the first floor. This facility has four resident bedrooms (two are dual occupancy), two shared half bathrooms, and separate shower room for resident use. There is a family room, living room with dining space, and a kitchen. A room for staff to take a rest break is located under the stairs. Access to the laundry room and garage is through locked doors for resident safety. LPA noted that the back patio has seating and shade for residents and visitors. The facility has battery operated smoke detectors in each room that are working, the carbon monoxide detector is in the family room above one of the doorways leading to the hallway with resident bedrooms and is functioning normally. LPA observed multiple fire extinguishers throughout the facility that are in the green compression range, purchased on 9/1/2025. LPA tested facility hot water at 108*(f), within regulation temperatures 105*-120* (f). LPA observed at least 2-days of perishable and at least 7-days of nonperishable foods. During today's visit LPA noted no obstructions in hallways, doorways or exits.

During the tour at approximately 10:00am, LPA observed Staff #1 (S1) and Staff #2 (S2) providing care to Resident #1 (R1) with the bedroom door fully open not providing R1 with privacy and Resident #2 (R2) walked by R1's open door during the care to access the half bathroom at the end of the hallway.

(Continued on LIC809-C)

NAME OF LICENSING PROGRAM MANAGER: Kelly Burley
NAME OF LICENSING PROGRAM ANALYST: Garrett Haner-Tomasko
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 12/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/12/2025
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 9
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 9
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: 12/12/2025
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
Medications are locked in a cabinet near the dining area. LPA conducted a sample medication audit and reviewed the facilities Centrally Stored Medication Records(CSMR), finding nine resident medications not documented on the CSMR and five expired medications. LPA conducted a staff and resident file review. LPA observed 4 of 4 resident reappraisals are not up to date or complete.

LPA and Licensee conducted a review of the annual care tool modules.

Exit interview conducted, deficiencies cited on LIC809-D pages, reports signed, and reports provided to Licensee.

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

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

DATE: 12/12/2025
LIC809 (FAS) - (06/04)
Page: 3 of 9
Document Has Been Signed on 12/12/2025 02:17 PM - It Cannot Be Edited


Created By: Garrett Haner-Tomasko On 12/12/2025 at 01:46 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: 12/12/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(a)(6)
Incidental Medical and Dental Care Services
(6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above when nine resident medications were not documented on the (CSMR) and five expired medications were observed in resident current stock of medications which poses a potential health and safety risk to persons in care.
POC Due Date: 12/26/2025
Plan of Correction
1
2
3
4
During LPA visit Licensee recorded the nine medications on the resident CSMR and documented the destruction of the five expired medications. Licensee will email LPA on or before 12/26/2025 a policy created to ensure medications are documented upon reciept to the facility and centrally stored medciations are audited regularly to check for expiration.
Type B
Section Cited
CCR
87463(b)
Reappraisals
(b) The reappraisal shall document significant changes in the resident's physical, mental, cognitive, behavioral, or functional condition, including those required to be documented as specified in Section 87466, Observation of the Resident.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and record review, the licensee did not comply with the section cited above in 4 out of 4 resident reappraisals not up to date or complete per regulation which poses a potential health and safety risk to persons in care.
POC Due Date: 01/02/2026
Plan of Correction
1
2
3
4
Licensee will review the full regulation 87463 and document up to date reappraisals for each of the four residents. The up dated reappraisals will be emailed to the LPA on or before 1/3/2026.
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: 12/12/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/12/2025


LIC809 (FAS) - (06/04)
Page: 4 of 9
Document Has Been Signed on 12/12/2025 02:17 PM - It Cannot Be Edited


Created By: Garrett Haner-Tomasko On 12/12/2025 at 01:46 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: 12/12/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87625(b)(8)
Managed Incontinence
(b) In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensee shall be responsible for the following: (8) Privacy shall be afforded when care is provided.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above when R1 was not provided privacy when recieving care from staff allowing other residents and visitors to see R1 while indicposed which poses a personal rights risk to persons in care.
POC Due Date: 12/26/2025
Plan of Correction
1
2
3
4
Licensee will conduct staff training with all staff ensuring residents are provided privacy during care and email the LPA the training documentation and signed staff roster on or before 12/26/2025.
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: 12/12/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/12/2025


LIC809 (FAS) - (06/04)
Page: 5 of 9