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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850557
Report Date: 09/17/2025
Date Signed: 09/17/2025 02:44:53 PM

Document Has Been Signed on 09/17/2025 02:44 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:NAVITA RESIDENCES ASHWOODFACILITY NUMBER:
565850557
ADMINISTRATOR/
DIRECTOR:		VIJAYAKUMAR,KARTHIGAFACILITY TYPE:
740
ADDRESS:390 N ASHWOOD AVETELEPHONE:
(805) 369-1255
CITY:VENTURASTATE: CAZIP CODE:
93003
CAPACITY: 6CENSUS: 5DATE:
09/17/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:55 AM
MET WITH:Karthiga (Karthi) VijayakumarTIME VISIT/
INSPECTION COMPLETED:
02:50 PM
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Licensing Program Analyst (LPA) Kelly Dulek arrived at the facility unannounced to conduct a required annual visit. LPA initially met with facility staff. Administrator was contacted via telephone and arrived at the facility at 10:20AM. Entrance interview conducted.

Beginning at 11:08AM, the LPA along with the Administrator toured the facility inside and outside to ensure resident health and safety and the facility is in compliance with Title 22 regulation. The smoke alarms and carbon monoxide detectors were tested and functioned properly. The fire extinguishers were purchased on 8/3/2024 and appeared fully charged.

BEDROOMS: The facility has seven (7) bedrooms total, one (1) of which is designated for staff use and six (6) are private resident rooms. All resident bedrooms were observed to contain a bed, chair, bedside table, dresser, and lighting. All resident rooms had appropriate bedding. There is an ample supply of linens and towels stored in the cabinets in the hallway. Bedrooms containing exit doors had functional auditory alarms. All residents have a wearable pendant to utilize when staff assistance is needed.

RESTROOMS: The facility has three (3) full bathrooms for resident and staff use and one half bath located at the entry. All restrooms contained grab bars and slip-resistant surfaces. Hot water was measured at 109.9 degrees Fahrenheit, which is within the required range.

COMMON AREAS: Paint, windows, blinds, and floors are in good repair. The common living and dining areas are clean and properly furnished. A working telephone is present. There is one (1) fireplace in the residence, which was properly screened at the time of the visit. Chemicals are stored in a locked cabinet in the laundry room and in the locked garage.


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: 09/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/17/2025
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: NAVITA RESIDENCES ASHWOOD
FACILITY NUMBER: 565850557
VISIT DATE: 09/17/2025
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OUTDOOR SPACE: The facility does have a small birdbath in the backyard; currently no residents are identified as at risk with this water feature. Building and grounds are free from hazard. Patio area observed outdoor shaded seating area for resident use. The one (1) outdoor exit gate was observed to be self-closing and self-latching.

KITCHEN: The kitchen contained a sufficient supply of dishes, glasses and utensils. The facility has a sufficient supply of non-perishable food, perishable food and an emergency supply of water is present. Knives are stored in a locked cabinet. Cleaning supplies were observed locked in a cabinet under the sink. The refrigerator/freezer was at the appropriate temperature (40*F and 0*F).

RECORD REVIEW: Beginning at 10:09AM (resident files) and 11:33AM (staff files), the LPA began file review. Staff and resident records were reviewed for documents including, but not limited to: health screening, TB test, staff training records, fingerprint clearance, resident physician's report, needs and service appraisal, and personal rights. All four (4) staff files and four (4) resident files observed were in compliance with regulation. All trainings were observed to be complete.

INFECTION CONTROL/EMERGENCY DISASTER PLANNING: LPA reviewed the facility's infection control practices and the facility's emergency disaster plan. The facility’s policies and procedures as it pertains to infection control are adequate. Emergency disaster drills are conducted quarterly, with the last drill documented on 06/30/2025. Emergency disaster plan was observed to be complete and updated annually, as required.

MEDICATION REVIEW: Medications for two (2) residents were reviewed. Medications were observed stored in a locked cabinet. Medications were prepared for a 7-day period and not in their original containers. Centrally Stored Medication and Destruction Record (CSMDR) was missing start dates for residents' current medications. Start dates observed on individual bubble packs did not match the medication counts. LPA was unable to tell whether medications are being administered as prescribed due to the inaccurate start dates and medications not stored properly. Medication Administration Record (MAR) was observed to be initialed daily for the month of September. A complete medication audit was unable to be completed at this time due to the improper storage and documentation.

INTERVIEWS: LPA interviewed two (2) residents and two (2) staff. No concerns noted.

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: 09/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2025
LIC809 (FAS) - (06/04)
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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: NAVITA RESIDENCES ASHWOOD
FACILITY NUMBER: 565850557
VISIT DATE: 09/17/2025
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DOCUMENTS REVIEWED/OBTAINED: During today's visit, the LPA reviewed a copy of the facility's register of facility clients, received a copy of the liability insurance and the facility's LIC 500.

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

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: 09/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/17/2025 02:44 PM - It Cannot Be Edited


Created By: Kelly Dulek On 09/17/2025 at 01:48 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 ASHWOOD
FACILITY NUMBER: 565850557

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/17/2025

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, as medications for residents were removed from their original containers and placed in a weekly medication container, start dates written were incorrect and due to the medication being stored incorrectly, LPA was unable to confirm whether medications are administered as prescribed, which poses an immediate health and safety risk to persons in care.
POC Due Date: 09/18/2025
Plan of Correction
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Administrator agreed to ensure medications are stored in their original containers effective immediately. Administrator will submit a statement of understanding to CCL by POC due date. Additional training will be provided to all staff assisting with medications by the end of the month and proof of training will be sent to CCL upon completion.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: 09/17/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/17/2025


LIC809 (FAS) - (06/04)
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