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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850268
Report Date: 07/24/2025
Date Signed: 07/24/2025 05:26:16 PM

Document Has Been Signed on 07/24/2025 05:26 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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:RESIDENCE AT DEAN LLC, THEFACILITY NUMBER:
565850268
ADMINISTRATOR/
DIRECTOR:		LIMBO, JOSEPHINEFACILITY TYPE:
740
ADDRESS:4032 DEAN DRIVETELEPHONE:
(805) 402-0304
CITY:VENTURASTATE: CAZIP CODE:
93003
CAPACITY: 5CENSUS: 3DATE:
07/24/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:20 PM
MET WITH:Amelia (Mae) DavisTIME VISIT/
INSPECTION COMPLETED:
04:50 PM
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Licensing Program Analyst (LPA) Kelly Dulek conducted case management visit to address deficiencies observed during the course of an unrelated complaint investigation. LPA initially met with facility staff and explained the reason for the visit. Facility Designee Amelia (Mae) Davis arrived at 02:25PM. Entrance interview conducted.

During a visit at the facility on 02/12/2025, LPA noticed an injury to Resident #1 (R1)’s face and upper body. LPA inquired with staff as to how R1 sustained the injury. Staff interviewed stated that R1 had fallen while at the facility and had received outside medical treatment for R1’s injuries. After R1’s fall, staff had rearranged R1’s furniture in their room to help prevent further injury. During file review, LPA reviewed records for Resident #2 (R2) who passed away in early 2023. LPA reviewed all unusual injury/incident reports sent to the Woodland Hills North Regional Office (RO) and noted that 0 (zero) incident reports and 0 (zero) death reports have been received at the RO since the date the facility was licensed on 09/06/2022. LPA interviewed facility designee, who stated that death reports were sent via email to the RO, however facility designee was unaware that injuries to residents needed to be reported in writing to the RO, so those had not been sent. LPA reminded facility designee of the requirement to send reports for all incidents that threaten the health or welfare of any resident in care within 7 days of any such occurrence.

Additionally, while interviewing staff and reviewing documents for R2, it was discovered that the facility was safeguarding R2’s items, such as R2’s wallet, including at least $500 cash, debit card, and green card. The facility did not maintain a LIC 621 for R2. Additionally, when R2 passed away and R2’s belongings were removed from the facility, the licensee did not sign or indicate R2’s items were removed. R2’s admission agreement indicates no refund will be issued following the death of any resident receiving hospice services. Report Continued on LIC 809-C

NAME OF LICENSING PROGRAM MANAGER: Kristin Heffernan
NAME OF LICENSING PROGRAM ANALYST: Kelly Dulek
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/24/2025
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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: RESIDENCE AT DEAN LLC, THE
FACILITY NUMBER: 565850268
VISIT DATE: 07/24/2025
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However, health and safety code requires a refund to be issued to all residents’ families/estates, regardless of receiving end of life care. LPA also noted that the facility’s admission agreement does not follow the title 22 requirements related to pre-admission policy and refunds.

Pursuant to Title 22 of the CA Code of Regulations and/or CA Health and Safety Code, the following deficiencies were cited (refer to LIC 809-D):

Exit interview conducted and copy of the report and appeal rights provided.

NAME OF LICENSING PROGRAM MANAGER: Kristin Heffernan
NAME OF LICENSING PROGRAM ANALYST: Kelly Dulek
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2025
LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 07/24/2025 05:26 PM - It Cannot Be Edited


Created By: Kelly Dulek On 07/24/2025 at 02:50 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: RESIDENCE AT DEAN LLC, THE
FACILITY NUMBER: 565850268

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/24/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/07/2025
Section Cited
CCR
87211(a)(1)

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87211 Reporting Requirements (a) (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events...if any; and disposition of the case.
This requirement is not met as evidenced by:
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Facility designee agreed to ensure all incident and death reports are submitted timely. A statement of understanding of the section related to reporting requirements will be signed by Administrator, Licensee representatives, and all facility designees and sent to CCL by POC due date.
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Based on record review, the licensee did not comply with the above cited section, as no incident or death reports from the date of licensure to the present time have been received at CCLand there were at least 2 (two) deaths and a fall incident, which poses a potential safety risk to persons in care.
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Type B
08/07/2025
Section Cited
CCR87217(j)

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87217 Safeguards for Resident Cash, Personal Property, and Valuables (j) Upon the death of a resident, all cash resources, personal property, and valuables of that resident shall immediately be safeguarded.
This requirement is not met as evidenced by:
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Facility Designee agreed to ensure residents' belongings are inventoried upon move in and safeguarded at the facility. A statement of understanding of this regulation section will be signed and sent to CCL by POC due date.
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Based on interview and record review, the licensee did not comply with the above cited section, as R1 did not have a record of any items brought into the facility, nor were items safeguarded or documented upon R1's death, which posed a potential 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.
Kristin Heffernan
NAME OF LICENSING PROGRAM MANAGER:
Kelly Dulek
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/24/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/24/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/24/2025 05:26 PM - It Cannot Be Edited


Created By: Kelly Dulek On 07/24/2025 at 02:59 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: RESIDENCE AT DEAN LLC, THE
FACILITY NUMBER: 565850268

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/24/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/07/2025
Section Cited
CCR
87507(g)(5)(A)

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87507 Admission Agreements (g) (5) (A) Facility policy concerning refunds, including the conditions under which a refund for advanced monthly fees will be returned in the event of a resident’s death, pursuant to Health and Safety Code section 1569.652.
This requirement is not met as evidenced by:
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Facility Designee agreed to discuss with Licensee Representative. Admission Agreement will be modified and sent to CCL for approval by POC due date.
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Based on record review, the licensee did not comply with the above cited section, as the facility's Admission Agreement states residents on hospice care will not receive a refund, which is not allowed per regulation and poses a potential 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.
Kristin Heffernan
NAME OF LICENSING PROGRAM MANAGER:
Kelly Dulek
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/24/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/24/2025


LIC809 (FAS) - (06/04)
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