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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850294
Report Date: 04/08/2025
Date Signed: 04/08/2025 04:06:19 PM

Document Has Been Signed on 04/08/2025 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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:VARSITY MANOR, THEFACILITY NUMBER:
565850294
ADMINISTRATOR/
DIRECTOR:		TECSON, ALEXANDERFACILITY TYPE:
740
ADDRESS:4656 VARSITY STTELEPHONE:
(805) 402-0304
CITY:VENTURASTATE: CAZIP CODE:
93003
CAPACITY: 6CENSUS: 3DATE:
04/08/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:11 PM
MET WITH:John Davis, Facility DesigneeTIME VISIT/
INSPECTION COMPLETED:
04:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Kelly Dulek conducted an unannounced Case Management - Deficiencies visit to this facility due to deficiencies observed during the investigation of complaint control # 29-AS-20250207094516. LPA met with Facility Designee John Davis and discussed the reason for the visit.

Upon entry during today’s visit, LPA observed 2 (two) of the facility’s hardwired smoke detectors had been removed in the facility dining room and the facility’s living room. Facility Designee stated the smoke detectors have been removed a least 2 (two) days ago. Administrator was contacted via telephone and stated they needed new batteries and were taken off site to replace the batteries. During today’s visit, Facility Designee picked up the smoke detectors and returned them to this facility.

During the course of the investigation, LPA interviewed Administrator, staff, and reviewed documents. Interview revealed that Resident #1 (R1) had fallen while in care at the facility on 04/28/2023. R1 also passed away under hospice care on 02/07/2025. LPA reviewed the Woodland Hills North Regional Office files for reports related to R1’s fall and subsequent hospitalization as well as R1’s death. LPA found that no reports have been received in the Regional Office via fax or email from this facility since the date the facility opened on 11/03/2022. LPA asked Administrator whether reports were submitted. Administrator stated he was unaware of the requirement to send incident reports to the Regional Office, however, Administrator stated he sent death reports via email. LPA asked for proof of emails sent to the Regional Office, but no such proof was provided during the investigation.

Pursuant to Title 22 Division 6 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. A copy of today’s reports were provided.

NAME OF LICENSING PROGRAM MANAGER: Kristin Heffernan
NAME OF LICENSING PROGRAM ANALYST: Kelly Dulek
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/08/2025
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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Document Has Been Signed on 04/08/2025 04:06 PM - It Cannot Be Edited


Created By: Kelly Dulek On 04/08/2025 at 02:03 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: VARSITY MANOR, THE
FACILITY NUMBER: 565850294

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/08/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/08/2025
Section Cited
CCR
87203

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87203 Fire Safety
All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic

This requirement is not met as evidenced by:
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During today's visit, Facility Designee picked up the missing smoke detectors, ensured the batteries are replaced and reinstalled them in the common areas. POC cleared.
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Based on observation and interview, the licensee did not compy with the above cited section, as 2 (two) smoke detectors were removed from the facility common areas for a minimum of 2 (two) days, which poses an immediate health and safety risk to persons in care.
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Type B
04/22/2025
Section Cited
CCR87211(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...name, findings, and treatment, if any; and disposition of the case.
This requirement is not met as evidenced by:
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The Administrator agreed to review all emails and see if/when death reports were sent to the Regional Office. If any were sent previously Administrator will provide proof to CCL by POC due date. Administrator will provide a statement of understanding related to reporting requirements, including hospice
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Based on interview and record review, the licensee did not comply with the above cited section, as no incident reports nor death reports have been received at the Regional Office since the facility opened, which poses a potential personal rights risk to residents in care.
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notifications 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: 04/08/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/08/2025


LIC809 (FAS) - (06/04)
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