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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850242
Report Date: 11/14/2025
Date Signed: 11/14/2025 04:27:17 PM

Document Has Been Signed on 11/14/2025 04:27 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:NAVITA RESIDENCES EDGEMONTFACILITY NUMBER:
565850242
ADMINISTRATOR/
DIRECTOR:		SHILA PANDEYFACILITY TYPE:
740
ADDRESS:1690 EDGEMONT DRTELEPHONE:
(805) 413-2455
CITY:CAMARILLOSTATE: CAZIP CODE:
93010
CAPACITY: 6CENSUS: 5DATE:
11/14/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:40 AM
MET WITH:Shila PandeyTIME VISIT/
INSPECTION COMPLETED:
04:45 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
Licensing Program Analyst (LPA) Valeria Conway conducted a Case Management - Deficiencies visit in conjunction with a complaint visit (Complaint Control # 29-AS-20251107111518). LPA arrived at 9:40 A.M. and met with facility staff, Mis “Nana” Sunariyati, who contacted via telephone facility administrator. At 10:15 A.M. Facility Designee Karthiga (Karthi) Vijayakumar and Administrator, Shila Pandey arrived at the facility.

The purpose of the report is to issue citations for deficiencies observed during the initial complaint investigation. Entrance interview conducted.

During today’s visit, the LPA conducted a brief plant tour at 10:20 A.M. to ensure there are no health and safety concerns, conducted interviews with the Administrator and facility designee, two (2) staff members, and three (3) residents between 10:00 A.M. and 1:30 P.M., conducted a resident file review, and obtained copies of relevant documents.

During the course of the investigation, LPA requested Resident’s #1 (R1’s) file. LPA observed that R1 was admitted in January 2024 and that the facility completed an appraisal/needs and service plan in August 2024. The need and services plan for 2025 was observed to be a duplicate of the 2024 document, with the only difference being that the last page was dated 8/11/2025. LPA further observed that the facility indicted progress notes were used as a method of evaluating the resident’s progress, however, when the LPA requested these notes, the administrator stated that neither management nor staff are keeping progress notes and that the forms need to be revised and completed accurately.

Continued on LIC 809-C

NAME OF LICENSING PROGRAM MANAGER: Desaree Perera
NAME OF LICENSING PROGRAM ANALYST: Valeria Conway
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 11/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/14/2025
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 4
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 4
Document Has Been Signed on 11/14/2025 04:27 PM - It Cannot Be Edited


Created By: Valeria Conway On 11/14/2025 at 12:58 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: NAVITA RESIDENCES EDGEMONT
FACILITY NUMBER: 565850242

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/14/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/26/2025
Section Cited
CCR
87463(i)

1
2
3
4
5
6
7
(i) When there is significant change in condition... or once every 12 months, whichever occurs first, the licensee shall arrange an in-person... to share the reappraisal with the resident, the resident's representative... This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Administrator will assess the resident and complete a new needs and services plan for R1 and submit new needs and service plan to LPA before POC due date.
8
9
10
11
12
13
14
Based on record review, the licensee did not comply with the section cited above by having R1's appraisal/needs and services plans not updated which poses/posed a potential health, safety or personal rights risk to persons in care.
8
9
10
11
12
13
14
Type B
11/26/2025
Section Cited
CCR87307(a)(3)(A)

1
2
3
4
5
6
7
(A) A bed for each resident, except that married couples may be provided with one appropriate sized bed. Each bed shall be equipped with good springs... This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Administrator agreed to submit an exception for R2 before POC due date.
8
9
10
11
12
13
14
Based on observation, the licensee did not comply with the section cited above by not applying for an exception for resident 2, which poses/posed a potential health, safety or personal rights risk to persons in care.
8
9
10
11
12
13
14
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Desaree Perera
NAME OF LICENSING PROGRAM MANAGER:
Valeria Conway
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 11/14/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/14/2025


LIC809 (FAS) - (06/04)
Page: 3 of 4
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: NAVITA RESIDENCES EDGEMONT
FACILITY NUMBER: 565850242
VISIT DATE: 11/14/2025
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
Continued from LIC 809

Additionally, at approximately 1:25 P.M., LPA interviewed Resident #2 (R2) in their room. During the interview, the LPA observed R2 seated in a recliner chair and noted that there was no bed in the room. R2 stated that they prefer to sleep in the recliner and do not wish to use a bed. While on site, a family member of R2 arrived and informed LPA that this has been R2’s long-standing preference and that they have slept in a recliner for many years. LPA revied R2’s physician’s report, which indicated that R2 must use a medical recliner to sleep. LPA asked the administrator whether an exception request had been submitted to the Department; however, the administrator confirmed that an exception had not been submitted.

Pursuant to Title 22, California Code of Regulations and/or CA Health and Safety Code, the following deficiencies were cited (refer to LIC 809-D.) Administrator was informed that failure to correct the deficiencies may result in civil penalties.

Exit interview conducted, appeal rights discussed, and a copy of this report and appeal rights were provided.

NAME OF LICENSING PROGRAM MANAGER: Desaree Perera
NAME OF LICENSING PROGRAM ANALYST: Valeria Conway
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 11/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2025
LIC809 (FAS) - (06/04)
Page: 4 of 4