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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850725
Report Date: 03/25/2026
Date Signed: 03/25/2026 04:40:06 PM

Document Has Been Signed on 03/25/2026 04:40 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:SUNRISE OF THOUSAND OAKSFACILITY NUMBER:
565850725
ADMINISTRATOR/
DIRECTOR:		MALONE, JASONFACILITY TYPE:
740
ADDRESS:3680 N MOORPARK RDTELEPHONE:
(805) 206-7860
CITY:THOUSAND OAKSSTATE: CAZIP CODE:
91360
CAPACITY: 158CENSUS: 115DATE:
03/25/2026
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Jason Malone, Executive Director (ED)-Sunrise TIME VISIT/
INSPECTION COMPLETED:
04:40 PM
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Licensing Program Analyst (LPA) Erica Mosley conducted a pre-licensing visit to the above-mentioned facility at 10 AM. LPA met with Belmont Village Executive Director (ED), Mark Ranno, and Belmont Village Director of Resident Care Services, Karen Pasten, along with the applicant / Executive Director (ED) / Regional Director of Operations Jason Malone. This application is for a Change of Ownership Application (CHOW) currently operating with Facility license # 565802433 and the current licensed facility has residents in care.

The facility is a four (4) story building that consists of a memory care unit, and an assisted living unit. There are fire sprinklers and fire doors throughout the facility. A physical plant tour was conducted inside and out. An approved fire clearance was received on 02/25/2026, clearing them for a capacity of 158, of which ten (10) may be bedridden, and 148 may be non-ambulatory. All rooms are approved for non-ambulatory and bedridden residents. An updated document of room numbers/locations of all bedridden residents shall be maintained and available to emergency responders upon request. Delayed egress is approved for the memory care unit. Age range 60 and over. Hospice care waiver submitted and is pending approval.

Common Areas: The facility maintained a comfortable temperature. Smoke detector(s) and carbon monoxide detector were operational at the time of the visit. There are fire extinguishers throughout the facility that were fully charged and were last serviced 04/04/2025. The LPA observed required postings throughout the common space. The LPA observed the stairwells, and they each had an emergency evacuation chair at the fourth floor. Activity Rooms were observed and clean at the time of visit. Fireplaces were observed adequately screened. LPA observed laundry rooms on all floors.

Report Continued on LIC 809C...

NAME OF LICENSING PROGRAM MANAGER: Kasandra Lopez
NAME OF LICENSING PROGRAM ANALYST: Erica Mosley
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 03/25/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/25/2026
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 4
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: SUNRISE OF THOUSAND OAKS
FACILITY NUMBER: 565850725
VISIT DATE: 03/25/2026
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(PAGE 2) Report Continued from LIC 809...
Bedrooms: The LPA observed fifteen (15) randomly selected resident bedrooms, of which five (5) were in memory care and ten (10) in assisted living. All resident rooms are set up with beds, nightstands, lamps, chests of drawers, chairs and closet space. The beds are furnished with box springs, comfortable mattress and clean linen; which includes, a mattress pad, top and bottom linens, pillowcases, blanket (if needed) and a bedspread. All rooms had a comfortable room temperature of 75 degrees Fahrenheit. Hot water temperature was measured in all fifteen (15) bathrooms and they were between the temperature range of 105-120 degrees Fahrenheit. Lighting in the rooms appeared adequate. In addition, no bedroom was used as a passageway to another room, bath or toilet. There is a brake room for staff at the facility. For nocturnal (NOC) shift, there will be awake night staff only. All rooms were free of odors. All window screens were clean and maintained in good repair. The resident bathroom(s) have a shower with non-skid materials. The toilets were in working conditions and the showers have grab bars.

Surrounding Grounds (Outdoors): The LPA observed appropriate outdoor furniture, with a covered shaded area for residents in both, the memory care unit courtyard and the assisted living courtyard. Parking is available for residents and visitors. LPA observed facility generator to function properly at the time of the visit.

Kitchen: The LPA inspected the kitchen/food service area the kitchen was observed to be inaccessible to residents in care. Knives are kept inaccessible to residents in care. Kitchen appliances were observed to be in operable condition. The facility has a sufficient supply of two (2) day perishable and seven (7) day non-perishable food. Dining room furniture was observed to be in good condition and appeared to be relatively clean. The supply of dishes, utensils, pots, pans and drink ware is adequate. Refrigerator and food pantry were checked for proper labels and expiration dates. The freezer was maintained at zero degrees Fahrenheit (0*F) and the refrigerator was maintained at 40*F. There are no pesticides (poisons) or toxins stored in any food storage area or preparation area with utensils. Trash cans had tight fitting lids. No flies or other vermin were observed. The LPA observed an adequate supply of emergency food and water. Report Continued on LIC 809C PAGE 3...

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

DATE: 03/25/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/25/2026
LIC809 (FAS) - (06/04)
Page: 3 of 4
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: SUNRISE OF THOUSAND OAKS
FACILITY NUMBER: 565850725
VISIT DATE: 03/25/2026
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(PAGE 3) Report Continued from LIC 809-C PAGE 2...

Medications: The medications are centrally stored in the wellness room located on the third floor along with a medication cart on the second floor for the memory care unit which remains locked at all times. First aid supplies were complete along with a current version of a first aid manual.

Resident and staff files will remain in Administrators offices, locked.

Component III was conducted in conjunction with the visit.

No corrections required on the pre-licensing visit at this time. Exit interview conducted. Report review and provided electronically.

This report will be sent to the Centralized Application Bureau (CAB). You will be notified by the CAB Analyst when your license has been approved. You are not allowed to begin operating until you have been notified that your license has been approved by the CAB Analyst. Failure to comply could affect approval of your license.

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

DATE: 03/25/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/25/2026
LIC809 (FAS) - (06/04)
Page: 4 of 4