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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850268
Report Date: 09/12/2025
Date Signed: 09/12/2025 04:54:25 PM

Document Has Been Signed on 09/12/2025 04:54 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: 2DATE:
09/12/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:50 AM
MET WITH:Amelia (Mae) DavisTIME VISIT/
INSPECTION COMPLETED:
05:05 PM
NARRATIVE
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Licensing Program Analyst (LPA) Kelly Dulek arrived at the facility unannounced to conduct a required annual visit at 09:50AM. When the LPA arrived, there were 2 (two) staff and 2 (two) residents present. Facility Designee Amelia (Mae) Davis arrived as facility staff opened the door and greeted the LPA.

Beginning at 10:03AM, LPA, along with Facility Designee, conducted a tour of the facility. The following was observed:

The facility is a single-story residence that consists of four (4) resident bedrooms and two (2) bathrooms. There is one (1) additional bedroom for staff use that is not identified on the approved fire clearance nor on the facility sketch. It appears a portion of the garage was converted into a staff room, however, Facility Designee could not confirm if permits or approval were obtained for this construction. The fire extinguisher appeared to be fully charged, but was last serviced on 09/06/2024. The hardwired smoke and carbon monoxide detectors were tested at 01:12PM and functioned properly. LPA observed required postings near the entry.

Bedrooms: The resident bedrooms were properly furnished with adequate lighting, and clean bedding. Both Resident #1 (R1) and Resident #2 (R2) had half bedrails on their beds, however there were no physician's orders indicating use of postural supports.

Bathrooms: The LPA observed one private resident bathroom, one bathroom used by staff, and one shared resident restroom. All bathrooms were clean, properly supplied and had functional fixtures. The LPA observed grab bars and slip-resistant surfaces. Residents have sufficient amounts of supplies for personal hygiene. Facility Designee was advised to secure all personal grooming and hygiene products present in the Report continued on LIC809-C

NAME OF LICENSING PROGRAM MANAGER: Kristin Heffernan
NAME OF LICENSING PROGRAM ANALYST: Kelly Dulek
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/12/2025
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 14
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 14
Document Has Been Signed on 09/12/2025 04:54 PM - It Cannot Be Edited


Created By: Kelly Dulek On 09/12/2025 at 01:31 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: 09/12/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87202(a)
Fire Clearance
(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above as the fire clearance does not include a converted garage/staff room, and the facility fire extinguisher has not been serviced annually, which poses an immediate health and safety risk to persons in care.
POC Due Date: 09/15/2025
Plan of Correction
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Facility Designee agreed to discuss with Licensee and Administrator and obtain proof of permitting/construction to the facility, will have the fire extinguisher serviced, and submit a new LIC 200 and facility sketch to CCLD by POC due date. If proper permits were not secured for the construction, Licensee will contact CCLD to modify the plan of correction before POC due date.
Type A
Section Cited
CCR
87355(e)(3)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 87355(c) or

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above as 1 (one) staff (Staff #1 - S1) does have criminal record clearance, but was not associated to this facility and has been working at this location for at least 2 (two) months, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/15/2025
Plan of Correction
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During today's visit, LPA associated S1 in Guardian to this facility. Licensee will send a statement of understanding of this regulation to CCLD by 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.
Kristin Heffernan
NAME OF LICENSING PROGRAM MANAGER:
Kelly Dulek
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/12/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/12/2025


LIC809 (FAS) - (06/04)
Page: 3 of 14
Document Has Been Signed on 09/12/2025 04:54 PM - It Cannot Be Edited


Created By: Kelly Dulek On 09/12/2025 at 01:31 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: 09/12/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(5)
Incidental Medical and Dental Care Services
(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 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 in 2 (two) of 2 (two) residents' medications observed were prepared in advance for 9 (nine) days and stored in weekly medication boxes, which poses an immediate health and safety risk to persons in care.
POC Due Date: 09/15/2025
Plan of Correction
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Facility Designee agreed to discontinue preparing medications in advance as of today's visit. Licensee will schedule an approved vendor or certified medical professional to conduct a medication training for all facility staff, including management. Proof of scheduled training will be sent to CCL by POC due date. Proof of training to include documentation of training topics covered, duration of training, trainer information, and attendees will be sent to CCL upon completion.
Type A
Section Cited
HSC
1569.69(b)
(b) Each employee who received training and passed the examination required in paragraph (5) of subdivision (a), and who continues to assist with the self-administration of medicines, shall also complete eight hours of in-service training on medication-related issues in each succeeding 12-month period.

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 Administrator is not present in the facility and no other staff files reviewed had annual medication training (last training was initial training in 2022 or 2023,) which poses an immediate health and safety risk to persons in care.
POC Due Date: 09/15/2025
Plan of Correction
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Facility Designee will communicate with Licensee. Licensee will schedule an approved vendor or certified medical professional to conduct a medication training for all facility staff, including management. Proof of scheduled training will be sent to CCL by POC due date. Proof of training to include documentation of training topics covered, duration of training, trainer information, and attendees will be sent to CCL upon completion.
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: 09/12/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/12/2025


LIC809 (FAS) - (06/04)
Page: 4 of 14
Document Has Been Signed on 09/12/2025 04:54 PM - It Cannot Be Edited


Created By: Kelly Dulek On 09/12/2025 at 01:31 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: 09/12/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87405(a)
87405 Administrator Qualifications and Duties (a) All facilities shall have a qualified and currently certified administrator. The licensee and the administrator may be one and the same person. The administrator shall have sufficient freedom from other responsibilities and shall be on the premises a sufficient number of hours to permit adequate attention to the management and administration of the facility as specified in this section. When the administrator is not in the facility, there shall be coverage by a designated substitute who shall have qualifications adequate to be responsible and accountable for management and administration of the facility as specified in this section. The Department may require that the administrator devote additional hours in the facility to fulfill his/her responsibilities when the need for such additional hours is substantiated by written documentation.
Deficient Practice Statement
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Based on observation and interview the licensee did not comply with the section cited above as the administrator is scheduled to be present M-F 09:00AM-01:00PM, however has not been present at any time when LPA has visited the facility, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/26/2025
Plan of Correction
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Facility Designee agreed to discuss with Licensee and Administrator a plan for coverage at the facility. Licensee will put in writing an administrative oversight plan for the facility and submit to CCLD by 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.
Kristin Heffernan
NAME OF LICENSING PROGRAM MANAGER:
Kelly Dulek
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/12/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/12/2025


LIC809 (FAS) - (06/04)
Page: 5 of 14
Document Has Been Signed on 09/12/2025 04:54 PM - It Cannot Be Edited


Created By: Kelly Dulek On 09/12/2025 at 01:31 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: 09/12/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(a)
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:

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 Administrator's file is not complete and/or present at the facility, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/26/2025
Plan of Correction
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Facility Designee contacted Administrator during the visit to request the file be brought to the facility, however this was unable to be completed. Facility Designee will ensure Administrator file is complete and is sent to CCLD by POC due date.
Type B
Section Cited
HSC
1569.618(c)(3)
(3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in as the 1 (one) overnight staff, who is scheduled to work 7 (seven) days a week does not have CPR or first aid training, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/26/2025
Plan of Correction
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Facility designee agreed to ensure S2 receives both CPR and first aid training and will send proof of training to CCL by 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.
Kristin Heffernan
NAME OF LICENSING PROGRAM MANAGER:
Kelly Dulek
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/12/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/12/2025


LIC809 (FAS) - (06/04)
Page: 6 of 14
Document Has Been Signed on 09/12/2025 04:54 PM - It Cannot Be Edited


Created By: Kelly Dulek On 09/12/2025 at 01:31 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: 09/12/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(e)
Incidental Medical and Dental Care Services
(e) For every prescription and nonprescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician on a prescription blank, maintained in the resident's file, and a label on the medication. Both the physician's order and the label shall contain at least all of the following information.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above as Resident #1 (R1) had over the counter medications and no prescription orders for these medications, which poses a potential health and safety risk to persons in care.
POC Due Date: 09/26/2025
Plan of Correction
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Facility Designee agreed to obtain physician's orders for all residents' medications and label all medications according to physician's orders. Designee will sent proof of physician's orders and labeled medications to CCL by 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.
Kristin Heffernan
NAME OF LICENSING PROGRAM MANAGER:
Kelly Dulek
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/12/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/12/2025


LIC809 (FAS) - (06/04)
Page: 7 of 14
Document Has Been Signed on 09/12/2025 04:54 PM - It Cannot Be Edited


Created By: Kelly Dulek On 09/12/2025 at 01:39 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: 09/12/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87608(a)(3)
Postural Supports
(a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions: (3) A written order from a physician indicating the need for the postural support shall be maintained in the resident's record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on record review, the licensee did not comply with the section cited above in 2 (two) of 2 (two) residents have half bedrails on their beds and neither resident had written physician's orders indicating the need for bed rails which poses a potential personal rights risk to persons in care.
POC Due Date: 09/26/2025
Plan of Correction
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Facility Designee agreed to obtain physician's orders for both residents' bedrails and submit proof to CCL by POC due date.
Type B
Section Cited
CCR
87632(d)(2)
Hospice Care Waiver
(2) The licensee shall notify the Department in writing within five working days of the initiation of hospice care services for any terminally ill resident in the facility or within five working days of admitting a resident already receiving hospice care services. The notice shall include the resident's name and date of admission to the facility and the name and address of the hospice.

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 Resident #2 (R2) was admitted to the facility on 04/01/2025 and was admitted to hospice care on the same date, but no notification was received at CCL indicating a resident is receiving hospice services, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/26/2025
Plan of Correction
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Facility designee agreed to discuss with licensee and ensure Licensee submits notification of R2's admit to hospice care. Licensee will ensure all staff, including licensee and Administrator are trained on reporting requirements and hospice care waiver reporting requirements by a qualified professional (approved vendor or health care professional) and proof of completed training will be sent to CCL by 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.
Kristin Heffernan
NAME OF LICENSING PROGRAM MANAGER:
Kelly Dulek
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/12/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/12/2025


LIC809 (FAS) - (06/04)
Page: 11 of 14
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: 09/12/2025
NARRATIVE
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shared resident restroom. The hot water was measured at 117.1 degrees Fahrenheit in the shared resident restroom, which is within the required limit of 105-120 degrees Fahrenheit.

Laundry Room: The laundry room cabinets were observed to be locked and contain laundry detergent and other chemicals.

Kitchen: The kitchen appeared clean and the appliances and fixtures functional during the time of visit. LPA observed a sufficient amount of perishable and non-perishable food at the facility. Sharp objects are stored in a locked drawer to the right of the stove and cleaning supplies are stored in a locked cabinet under the sink. Upon arrival, LPA noted the drawer to be unlocked. LPA advised to keep the drawer locked at all times if any residents are at risk with access to any items stored inside.

Common Areas: These included the living room and dining area. The common areas were checked for cleanliness and furniture was checked for functionality during time of visit. The facility maintained a comfortable temperature throughout the visit.

Surrounding Grounds (Outdoors): There was a shaded area with proper furniture for outdoor use. There are no bodies of water on the premises. Exit gate was observed to be self-closing and self-latching.

Garage: The garage is where additional non-perishable emergency food items are held. Cleaning supplies and disinfectants are kept in the garage. The garage is locked and inaccessible to the residents in care. Facility designee indicated the facility does not have emergency water.

File review: Began at 10:20AM. LPA reviewed both residents' files. Resident #2 (R2) was admitted to hospice care on 04/01/2025, however no notification was sent to CCLD as required. LPA reviewed personnel files for 4 (four) staff, including Administrator. The Administrator has not been present at any CCLD visits observed in the facility's history, since the pre-licensing visit in 2022. LPA obtained a copy of the facility's LIC 500, which indicates Administrator is present Monday - Friday 09:00AM to 01:00PM, however was again unavailable during today's visit. Administrator did not have a full and complete file for review at the facility, nor was Administrator able to bring a copy to the facility during today's visit. Administrator is missing a health screening, results from a tuberculosis test, first aid/CPR training, and personnel report. Staff #1 (S1) has been working at the facility for at least 2 months and does have a fingerprint background clearance, however was not associated to this facility. S1 also does not have a health screening or results of a tuberculosis test 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: 09/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2025
LIC809 (FAS) - (06/04)
Page: 13 of 14
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: 09/12/2025
NARRATIVE
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on file at this location. None of the 4 (four) staff files reviewed contained proof of the required annual medication training. Additionally, both the Administrator and Staff #2 (S2) did not have proof of CPR nor first aid training. S2 works alone during the overnight shift.

Emergency Disaster Plan/Infection Control: The LPA reviewed the facility's Infection Control Plan, Disaster Plan and evacuation drills. Emergency Disaster plan has not been updated since 2022 and contains outdated information. Infection control plan appeared to be complete and updated annually as required. Emergency disaster drills are conducted quarterly, with the last evacuation drill documented on 06/08/2025.

Interviews: LPA conducted interviews with 2 (two) residents and 2 (two) staff. No immediate concerns were voiced during the visit.

Medication audit: Medications were reviewed beginning at 12:30PM. Medications are centrally stored and locked in a cabinet in the common area. LPA observed medications to be prepared for a 2-week time period, with 9 (nine) days remaining in the pre-prepared medication boxes. Centrally Stored Medication and Destruction Records (CSMDR) for both residents were reviewed and compared to medications present. However, start dates were incorrect as well as refill information and prescription numbers were illegible. Medication start dates were written in including dates in the future. It's possible this is due to the medications being prepared well in advance and improperly stored, however start dates could not have been correct based on medication counts. A complete medication audit was unable to be completed at this time due to the improper storage and documentation. LPA also observed that R1 has over the counter medications, including Bayer Aspirin, Vitamin D3, Centrum Women 50+, and Vitamin C, which were not labeled nor were there prescription orders for these medications. No PRN authorization forms were present for either resident.

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). 2 (two) civil penalties were assessed, each for $500.

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

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

DATE: 09/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2025
LIC809 (FAS) - (06/04)
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