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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405800987
Report Date: 03/11/2026
Date Signed: 03/11/2026 02:25:04 PM

Document Has Been Signed on 03/11/2026 02:25 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: 3DATE:
03/11/2026
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:50 AM
MET WITH:Licensee/Administrator - Angelita MaravillasTIME VISIT/
INSPECTION COMPLETED:
02:35 PM
NARRATIVE
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On March 11, 2025 at 9:50am, 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 July 1, 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 Licensee/Administrator Angelita Maravillas 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 10:05am, LPA and Licensee conducted a walk through of the facilities first floor where residents reside, the second floor is only accessed by facility staff. In bedroom #2 LPA noted two electrical outlets with no faceplates, leaving wires accessible.

LPA and Licensee conducted a review of the facilities Centrally Stored Medications and Destruction Records (CSMDR) and the centrally stored medications for all three residents in care. During the review LPA and Licensee noted Resident #1 (R1) has a tube of triamcinolone 0.1% cream not logged on R1's CSMDR. Resident #2 (R2) with a bottle of quetiapine 25mg, pharmacy label states quantity thirty (30), instructions take one tablet by mouth every day, a physician order dated 11/12/25 states take one tablet by mouth twice daily and the CSMDR states this bottle was started November 2025 with no day noted. Had the medication been given as prescribed the medication from this bottle would have run out in fifteen days but a count of the pills in the bottle revealed eighty-six (86) pills, Licensee stated the reason there were more pills in the bottle

(Contniued on LIC809-C)

NAME OF LICENSING PROGRAM MANAGER: Kelly Burley
NAME OF LICENSING PROGRAM ANALYST: Garrett Haner-Tomasko
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 03/11/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/11/2026
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: 03/11/2026
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than the label stated was because they did not have enough pills and they took pills they had left over from a former resident and poured them into this bottle. A second bottle of quetiapine 25mg for R2 contained ninety (90) pills matching the quantity on the pharmacy label, the CSMDR for this medication states started on 3/8/2026. A review of Resident #3's (R3's) medication and CSMDR revealed a bottle of levothyroxine 75mcg with instructions to take one tablet by mouth every morning, a quantity of ninety (90) pills and start date of October 30, 2025; a count of the medications in the bottle revealed twenty-nine (29) dark blue pills with a stamp P3 indicating the pill dosage of 75mcg and three (3) light blue pills with a stamp P4 indicating 88mcg; Licensee stated R3's order changed from 88mcg to 75mcg and they must have combined the medications into this bottle; with a start date of October 30, 2025 at a quantity of ninety (90) this would be a ninety day supply. R3 also has a bottle of lisinopril 10mg with instructions take one tablet by mouth daily, and started on October 30, 2025; a count of the bottle revealed six (6) pills of the medication and a seventh pill with stamp of U25 matching R3's quetiapine 25mg bottle.

Administrator stated they would destroy the medications that are mixed in bottles, stop using medications prescribed for other people, and ensure residents are receiving medications as prescribed.

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: 03/11/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2026
LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 03/11/2026 02:25 PM - It Cannot Be Edited


Created By: Garrett Haner-Tomasko On 03/11/2026 at 01:49 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: 03/11/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/12/2026
Section Cited
CCR
87465(a)(4)

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Incidental Medical and Dental Care
(a) A plan for incidental medical and dental care shall be developed by each facility... (4)The licensee shall assist residents with self-administered medications as needed.This requirement was not met as evidenced by:
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Licensee removed and will destroy the mixed medications and they will write a procedure on using one bottle at a time and properly documenting start dates, email this to LPA by 3/12/2026. Additional Licensee will sign up for vendored medication training and email LPA confirmation for all three staff.
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Based on observation, interview and record review, the licensee is not providing reisdents their medications as prescribed, which poses an immediate Health, Safety, Personal Rights risk to persons in care.
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Type A
03/12/2026
Section Cited
CCR87465(h)(5)

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(h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers.This requirement was not met as evidenced by:
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Licensee states they will no longer mix medication and will incldue this in the procedure for the above plan of correction and email to LPA by 3/12/2026.
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Based on observation, interview, and record review, the licensee tansffered medications into three different medication bottles which poses an immediate Health, Safety, and 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: 03/11/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/11/2026


LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 03/11/2026 02:25 PM - It Cannot Be Edited


Created By: Garrett Haner-Tomasko On 03/11/2026 at 01:54 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: 03/11/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/25/2026
Section Cited
CCR
87303(a)

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Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times...
This requirement was not met as evidenced by:
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Licensee will have the outlets covered with faceplates and email LPA pictures by 3/25/2026.
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Based on observation, the licensee did not ensure two electrical outlets were covered with faceplates which poses a potential Health and Safety 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: 03/11/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/11/2026


LIC809 (FAS) - (06/04)
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