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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425850600
Report Date: 04/15/2025
Date Signed: 04/15/2025 05:29:40 PM

Document Has Been Signed on 04/15/2025 05:29 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:PEDFLOR'S RESIDENTIAL CARE IIFACILITY NUMBER:
425850600
ADMINISTRATOR/
DIRECTOR:		ALEJANDRO,AUREAFACILITY TYPE:
740
ADDRESS:1315 E ALVIN AVENUETELEPHONE:
(805) 266-2950
CITY:SANTA MARIASTATE: CAZIP CODE:
93454
CAPACITY: 6CENSUS: 3DATE:
04/15/2025
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:03 PM
MET WITH:Aurea Alejandro, Restie AlejandroTIME VISIT/
INSPECTION COMPLETED:
05:40 PM
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Licensing Program Analyst (LPA) Rankin arrived at the facility announced at 3:03 p.m. to conduct a pre-licensing inspection. LPA met with Administrator Aurea Alejandro. This is a change of ownership application from Pedflor Alejandro, LLC. to Pedflor Alejandro I LLC. The current census is three (3) residents. The fire clearance was granted on 12/18/24; in which two (2) rooms were cleared for non-ambulatory residents and one (1) room for bedridden residents. Component III was reviewed with administrator for Residential Care Facility for the Elderly (RCFE)’s.

The LPA toured the physical plant areas inside and outside with the applicant to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations.

BEDROOMS: There are four (4) bedrooms in the facility; the facility has three (3) rooms for resident use, and one (1) staff room. Staff room is kept locked. All resident rooms have doors to the outside. Lighting in the rooms appeared adequate. All rooms were set up with beds, night stands, lamps, chests of drawers, chairs and closet space.

BATHROOMS: There is two (2) full bathrooms for resident use. The bathroom in the hallway is designated for staff and resident use, one (1) bathroom is in a private room designated for resident use. The showers are equipped with nonskid surfaces and available nonskid mats. Grab bars were observed in the bathrooms.

Continued on LIC 809-C.

NAME OF LICENSING PROGRAM MANAGER: Kelly Burley
NAME OF LICENSING PROGRAM ANALYST: Melisa Rankin
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/15/2025
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 N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: PEDFLOR'S RESIDENTIAL CARE II
FACILITY NUMBER: 425850600
VISIT DATE: 04/15/2025
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COMMON AREA: The common areas were appropriately furnished, and the lighting was adequate. There is a television and other entertainment equipment in the living room area. The facility smoke alarm system was tested and working at time of visit. There is a charged fire extinguisher located in the living room area. Last inspected in August of 2024. There is a functioning telephone on the premises. Emergency exiting plans/sketch are posted. Emergency telephone numbers are posted. All other required postings are also posted in the hall and common areas.

KITCHEN: Kitchen knives are stored locked and inaccessible in a drawer on the left side of the kitchen sink. The supply of perishable and nonperishable food is adequate. The supply of dishes is adequate. Appliances in the kitchen are clean and functional. There is an adequate supply of emergency food.

MEDICATIONS: Medications are in a locked cabinet in the kitchen. The first aid supplies were complete.

FILES: Resident and staff records were reviewed and complete.

LAUNDRY: The laundry area is located in the attached garage. Laundry detergent and chemicals are locked and stored inaccessible.

EXTERIOR: The exterior passageways were clean and clear of any obstructions. The backyard is set up with a table, which is located under a shaded structure along with chairs for resident use. There are no bodies of water noted on the premises. The back and sides of the house are separated from the front yard by gates. Gates have a self-latching mechanism. There are no other structures on the property.

INFECTION CONTROL: The facility has an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. If needed, the facility has the capacity to designate a single isolation room if needed.

Facility is in compliance with Title 22 Regulations at this time. This report will be sent to the Centralized Application Bureau (CAB). The CAB Analyst will notify the applicant when the license has been approved. The applicant is aware that they are unable to operate under the new license number until they have been notified that the license has been approved by the CAB Analyst. Failure to comply could affect approval of the license.

Exit interview conducted and report issued.

NAME OF LICENSING PROGRAM MANAGER: Kelly Burley
NAME OF LICENSING PROGRAM ANALYST: Melisa Rankin
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2025
LIC809 (FAS) - (06/04)
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