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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850431
Report Date: 05/16/2025
Date Signed: 05/16/2025 02:45:47 PM

Document Has Been Signed on 05/16/2025 02:45 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:CINNAMON GARDEN HOMEFACILITY NUMBER:
565850431
ADMINISTRATOR/
DIRECTOR:		FRAME, TAMMYFACILITY TYPE:
740
ADDRESS:1534 WAKEFIELD AVETELEPHONE:
(805) 870-4193
CITY:THOUSAND OAKSSTATE: CAZIP CODE:
91360
CAPACITY: 6CENSUS: 5DATE:
05/16/2025
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:10 AM
MET WITH:Tammy Frame - Administrator TIME VISIT/
INSPECTION COMPLETED:
02:50 PM
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Licensing Program Analyst (LPA) Erica Mosley arrived at the facility unannounced to conduct an unannounced Case Management - Annual Continuation to continue the inspection that began on 05/09/2025. LPA Mosley entered the facility at 10:10 a.m. Upon arrival, LPA Mosley was greeted by staff and Administrator. LPA met with Administrator, Tammy Frame and explained the reason for the visit. The LPA and Administrator briefly toured the physical plant areas inside and outside at 10:20 a.m. to ensure there were no health and safety hazards and facility is in compliance with Title 22 Regulations. Entrance interview conducted.

Infection Control / Emergency disaster planning: During today’s visit LPA Mosley reviewed the facility’s infection control practices and emergency disaster plan. The facilities policies and procedures as they pertain to infection control and emergency preparedness are satisfactory.

RECORDS: Records review began at 10:51 a.m., five (5) resident records were reviewed for, but not limited to: signed admission agreements, current medical assessments with TB results, LIC627(c) Consent for Treatment form, current needs and services plan, and hospice records. All records in order. At 12:08 p.m. three (3) Personnel records including the Administrator’s file were reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All files were in order.

Report Continued on LIC 809-C


NAME OF LICENSING PROGRAM MANAGER: Kasandra Lopez
NAME OF LICENSING PROGRAM ANALYST: Erica Mosley
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/16/2025
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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: CINNAMON GARDEN HOME
FACILITY NUMBER: 565850431
VISIT DATE: 05/16/2025
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(PAGE 2) Report Continued from LIC 809...

MEDICATIONS: Medications review began at approximately 1:26 p.m. Medications are centrally stored and locked in a kitchen cabinet. Medications requiring refrigeration are securely stored in a locked box inside the refrigerator, which is kept in the garage that remains locked at all times. Medications for five (5) residents were reviewed. Medications are labeled and checked for expiration dates. All medications were labeled, stored, and locked inaccessible to residents in care. Medications reviewed were found to be self-administered as prescribed and documented on the centrally stored medication and destruction records. No errors observed.

DOCUMENTS: Documents obtained during the visit include: LIC 500 facility roster, LIC 9020A Resident roster, and current Liability Insurance.

No deficiencies cited at this time. Exit interview conducted. A copy of the report was reviewed and issued.

NAME OF LICENSING PROGRAM MANAGER: Kasandra Lopez
NAME OF LICENSING PROGRAM ANALYST: Erica Mosley
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2025
LIC809 (FAS) - (06/04)
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