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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565802416
Report Date: 12/15/2025
Date Signed: 12/15/2025 04:06:40 PM

Document Has Been Signed on 12/15/2025 04:06 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:VILLA TERESA RESIDENTIAL CAREFACILITY NUMBER:
565802416
ADMINISTRATOR/
DIRECTOR:		MARTINEZ, TINA MARIEFACILITY TYPE:
740
ADDRESS:821 TERESA STREETTELEPHONE:
(805) 604-7772
CITY:OXNARDSTATE: CAZIP CODE:
93030
CAPACITY: 6CENSUS: 6DATE:
12/15/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:15 AM
MET WITH:George YazbekTIME VISIT/
INSPECTION COMPLETED:
04:15 PM
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 Licensing Program Analyst (LPA) Trevor Byrne arrived at the facility unannounced to conduct the required annual visit at 11:15 AM. LPA met with facility staff who contacted the facility Administrator Tina Marie Martinez and Licensee Representative George Yazbek. The Licensee Representative arrived to the facility at 11:22 AM and the Administrator arrived to the facility at 11:25 AM. Entrance interview was conducted and the reason for the visit was explained.

Beginning at 11:23 AM the LPA, along with the Licensee Representative and later the facility Administrator toured the physical plant areas inside and outside to ensure there are no health and safety hazards and that facility is in compliance with Title 22 Regulations. The following was observed:

COMMON AREAS: This includes the living rooms, hallway, and dining area. LPA observed the living rooms to be clean and properly furnished at the time of the visit. The living rooms contained activities for resident use including a television. The living rooms contained an appropriately screened fireplace, locked cabinets, and drawers which contained resident medications and resident, staff, and facility files. LPA observed the living rooms to contain a complete first aid kit and the facility’s telephone. The hallway was observed to be clean and free from any obstructions. The hallway contained closets that contained storage for linens and care supplies. The dining area was observed to be equipped with adequate seating for resident use. The common areas contained all required postings. The facility’s fire and carbon monoxide alarms were tested between 12:35 PM and 12:37 PM and were functional at the time of the visit. All exits in the facility were observed to contain functioning auditory alarms. Continued on LIC 809C.
NAME OF LICENSING PROGRAM MANAGER: Kasandra Lopez
NAME OF LICENSING PROGRAM ANALYST: Trevor Byrne
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 12/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/15/2025
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.

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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: VILLA TERESA RESIDENTIAL CARE
FACILITY NUMBER: 565802416
VISIT DATE: 12/15/2025
NARRATIVE
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COMMON AREAS CONT: LPA observed an unsecured bottle of Mucus Relief medication stored in a hallway drawer. LPA informed the Administrator who immediately secured the medication.

BEDROOMS: There are five (5) bedrooms in the facility; two (2) are dual occupancy resident rooms, two (2) are single occupancy resident rooms, and one (1) is a staff room. LPA, the Licensee Representative, and the facility Administrator toured all five (5) bedrooms. All resident rooms were observed to be furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting. Bedroom #1 contained a direct exit to the outdoors of the facility that was observed to be blocked by a chair. LPA informed the Licensee Representative who removed the obstruction at the time of the visit. LPA observed Resident #1 (R1)’s bed to contain full bed rails. LPA observed the screen door of room #1 to contain two (2) small tears in the screening material. LPA informed the Licensee Representative who performed repairs to the material at the time of the visit.

KITCHEN: The LPA observed the kitchen area to be clean. Kitchen appliances appeared to be in operable condition. The facility had a sufficient supply of two (2) days perishable and seven (7) days non-perishable food. LPA observed a secured under-sink cabinet to contain cleaning chemicals. LPA observed secured drawers to contain knives and other sharp objects. LPA observed the kitchen to contain a wall mounted fire extinguisher to be fully charged and purchased on 02/14/2025.

BATHROOMS: There are two (2) bathrooms at the facility. One is designated as a shared/common resident bathroom and one (1) is a private resident bathroom. Both resident bathrooms were observed to be clean and were equipped with nonskid surfaces. Grab bars were observed in all resident showers and near all resident toilets, all were properly secured. The water temperature was measured to be between 116.4 and 118.0 degrees Fahrenheit, which is in compliance with regulation. Both bathrooms contained secured storage which contained grooming supplies and cleaning supplies.

GARAGE: The garage was observed to be locked and inaccessible to clients in care. LPA observed the garage to contain the facility’s washer and dryer, extra care supplies, sufficient emergency water supplies, an extra refrigerator/freezer, and locked cabinets which contained cleaning supplies and laundry supplies. Additionally, the garage was observed to contain a locked staff break room.
Continued on LIC 809C.
NAME OF LICENSING PROGRAM MANAGER: Kasandra Lopez
NAME OF LICENSING PROGRAM ANALYST: Trevor Byrne
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2025
LIC809 (FAS) - (06/04)
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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: VILLA TERESA RESIDENTIAL CARE
FACILITY NUMBER: 565802416
VISIT DATE: 12/15/2025
NARRATIVE
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OUTDOOR SPACE: The facility has two (2) emergency exit gates located on either side of the facility; LPA observed clear passageways for emergency exit use. The facility had adequate shaded seating outdoors for resident use. LPA observed the outdoors of the facility to contain a locked storage shed which contained gardening supplies and extra care supplies. LPA observed a camera located at the entrance of the facility.

RECORD REVIEW: Record review began at 12:25 PM. Staff and resident records were reviewed for documents including, but not limited to: health screening, TB test, staff training records, fingerprint clearance, resident physician's report, needs and service appraisal, consent forms, and personal rights. Five (5) staff files were reviewed. LPA observed staff trainings to be missing the name of the instructor who performed the training and the number of hours per training subject. Additionally, LPA observed one (1) staff file to be missing the twenty (20) hours of required annual training. LPA informed the Administrator of the missing trainings and the Administrator agreed to conduct trainings with staff members on the topics required by regulations. Six (6) resident files were reviewed. LPA observed R1’s bed to contain full bed rails. During file review LPA observed that R1 was not enrolled with hospice care. LPA informed the Licensee Representative that bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails. The Licensee Representative expressed understanding and removed the full length bed rails from R1’s bed at the time of the visit. LPA observed Resident #2 (R2)’s Appraisal Needs and Services plan to be dated 10/03/2024. LPA informed the Administrator that resident appraisals shall be updated in writing as frequently as necessary or once every 12 months, whichever occurs first. The Administrator expressed understanding and completed an updated Appraisal Needs and Services plan for R2 at the time of the visit.

MEDICATION REVIEW: Medication review began at 02:05 PM. Medications for three (3) of six (6) residents were observed. All medications were stored properly and were appropriately documented on their respective centrally stored medication and destruction record sheets. No deficiencies were observed during medication review.

Continued on LIC 8809C.
NAME OF LICENSING PROGRAM MANAGER: Kasandra Lopez
NAME OF LICENSING PROGRAM ANALYST: Trevor Byrne
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2025
LIC809 (FAS) - (06/04)
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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: VILLA TERESA RESIDENTIAL CARE
FACILITY NUMBER: 565802416
VISIT DATE: 12/15/2025
NARRATIVE
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INFECTION CONTROL/EMERGENCY DISASTER PLANNING: During today’s visit, the LPA reviewed the
facility's infection control practices and the facility's emergency disaster plan. The facility’s policies and procedures as they pertain to infection control are adequate. Emergency disaster drills are conducted quarterly; the facility’s last logged emergency disaster drill was conducted on 09/03/2025. The facility’s emergency disaster plan is up to date and is adequate. Both the infection control plan and the emergency disaster plan are reviewed/updated annually by the facility’s Administrator.

INTERVIEWS: LPA interviewed two (2) residents. The residents interviewed stated that they had no recommendations for improvement for the facility. LPA interviewed two (2) staff members. One (1) staff member interviewed was knowledgeable on their roles and responsibilities, the resident’s rights, the forms of abuse, and the appropriate reporting procedures for suspected abuse. One (1) staff member interviewed was unable to appropriately identify the different forms of abuse but was knowledgeable on their roles and responsibilities, the resident’s rights, and the appropriate reporting procedures for suspected abuse.

During today’s visit LPA obtained a copy of the facility’s LIC 500, resident roster, and current liability insurance.

Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D): Exit interview conducted and copy of the report was issued. LPA experienced technical difficulties while printing appeal rights. Appeal Rights will be emailed to Licensee at a later date.

NAME OF LICENSING PROGRAM MANAGER: Kasandra Lopez
NAME OF LICENSING PROGRAM ANALYST: Trevor Byrne
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2025
LIC809 (FAS) - (06/04)
Page: 5 of 25
Document Has Been Signed on 12/15/2025 04:06 PM - It Cannot Be Edited


Created By: Trevor Byrne On 12/15/2025 at 03:32 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: VILLA TERESA RESIDENTIAL CARE
FACILITY NUMBER: 565802416

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/15/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(2)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above as a mucus relief medication was left unsecured in the hallway drawer accessible to clients in care which poses an immediate health or safety risk to persons in care.
POC Due Date: 12/15/2025
Plan of Correction
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The medication was secured by the Administrator at the time of the visit. POC cleared.
Type A
Section Cited
CCR
87608(a)(5)(B)
Postural Supports
(B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above as a resident who was not on hospice had full bed rails installed on their bed which poses an immediate personal rights risk to persons in care.
POC Due Date: 12/15/2025
Plan of Correction
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Bed rail was removed and replaced with half rails at the time of the visit. POC cleared.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Kasandra Lopez
NAME OF LICENSING PROGRAM MANAGER:
Trevor Byrne
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 12/15/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/15/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/15/2025 04:06 PM - It Cannot Be Edited


Created By: Trevor Byrne On 12/15/2025 at 03:32 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: VILLA TERESA RESIDENTIAL CARE
FACILITY NUMBER: 565802416

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/15/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87307(d)(6)
Personal Accommodations and Services
(6) All outdoor and indoor passageways and stairways shall be kept free of obstruction.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above as bedroom #1's emergency exit door was blocked by a chair which posed a potential safety risk to persons in care.
POC Due Date: 12/15/2025
Plan of Correction
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Chair was removed at the time of the visit. POC cleared.
Type B
Section Cited
CCR
87412(c)(2)
Personnel Records
(c) Licensees shall maintain in the personnel records verification of required staff training and orientation. (2) Documentation of staff training shall include:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above as in-service trainings did not have the name of the trainer or the number of training hours per subject which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/29/2025
Plan of Correction
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Licensee Representative agreed to submit their template that they will utilize to track in-service trainings to CCLD no later than POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Kasandra Lopez
NAME OF LICENSING PROGRAM MANAGER:
Trevor Byrne
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 12/15/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/15/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/15/2025 04:06 PM - It Cannot Be Edited


Created By: Trevor Byrne On 12/15/2025 at 03:32 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: VILLA TERESA RESIDENTIAL CARE
FACILITY NUMBER: 565802416

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/15/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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3
4
Based on record review, the licensee did not comply with the section cited above as one (1) employee did not have the required annual trainings in their staff file which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/29/2025
Plan of Correction
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Licensee Representative agreed to conduct the required trainings with the identified employee and to submit proof of completed training to CCLD no later than POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
Kasandra Lopez
NAME OF LICENSING PROGRAM MANAGER:
Trevor Byrne
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 12/15/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/15/2025


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