<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 567609722
Report Date: 06/06/2025
Date Signed: 06/06/2025 04:44:18 PM

Document Has Been Signed on 06/06/2025 04:44 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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:GRANNYS HOMEFACILITY NUMBER:
567609722
ADMINISTRATOR/
DIRECTOR:		HERNANDEZ, VICTORFACILITY TYPE:
740
ADDRESS:1831 BERNADETTE STTELEPHONE:
(805) 278-2273
CITY:OXNARDSTATE: CAZIP CODE:
93030
CAPACITY: 6CENSUS: 6DATE:
06/06/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:15 PM
MET WITH:Victor Hernandez TIME VISIT/
INSPECTION COMPLETED:
04:45 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Esther Cortez arrived at the facility unannounced to conduct a required annual visit at 03:15 PM. LPA met with facility staff and explained the reason for the visit. Staff reached out to Licensee/Administrator Victor Hernandez who arrived shortly after. Entrance interview conducted.

The LPA, along with Licensee/Administrator toured the physical plant areas inside and outside to ensure there are no health and safety hazards and that facility is in compliance with Title 22 Regulations. The following was observed:

Fire extinguisher is fully charged and recently serviced on 06/04/2025. Smoke detectors and Carbon monoxide detector was tested and was functional at the time of the visit. Fire alarm is centrally located and can not be shut off without the fire department on site at the facility.

KITCHEN: Kitchen was observed to be clean. Kitchen appliances appeared to be in operable condition. The facility has a sufficient supply of 7 (seven) days non-perishable and 2 (two) days perishable food. Knives were observed to be locked in a drawer. Cleaning supplies are located in a locked under-sink cabinet.

GARAGE: The garage is kept locked and inaccessible to clients in care. A washer and dryer were observed and laundry chemicals were properly stored. The facility maintains an adequate supply of emergency food and water for all residents and staff members.

BEDROOMS: There are 5 (five) total bedrooms in the facility; 2 (two) are designated as private resident rooms, 2 (two) are designated as shared resident rooms, and 1 (one) is utilized as a staff room. All resident rooms were observed to be furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. Report Continued on LIC 809-C

NAME OF LICENSING PROGRAM MANAGER: Kasandra Lopez
NAME OF LICENSING PROGRAM ANALYST: Esther Cortez
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 06/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/06/2025
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 3
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 3
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: GRANNYS HOME
FACILITY NUMBER: 567609722
VISIT DATE: 06/06/2025
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
BATHROOMS: There are 2 (two) bathrooms for resident use. One common restroom and one restroom in a shared resident's room. Restrooms were observed to contain nonskid mats. Grab bars were observed in showers and next to toilets. The LPA tested the water temperature in the common bathroom, the temperature was observed to be 118.2 degrees Fahrenheit, within the required range.

COMMON AREAS: This includes the living room and dining room areas. LPA observed common areas to be clean and properly furnished at the time of the visit. The living room has a properly screened fireplace. Exit doors contain alarms and all were functional at the time of the visit.

OUTDOOR SPACE: The backyard has adequate shaded sitting areas with patio furniture including tables and chairs for resident use. There is a latched self-closing side gates for client use. There were no bodies of water on the premises. An outdoor shed was observed to be locked containing extra care supplies. A generator was observed outdoors for use in emergencies.

Due to time constraints the LPA will return at a later time to complete the annual.

No deficiencies cited. Exit interview conducted and report provided.

NAME OF LICENSING PROGRAM MANAGER: Kasandra Lopez
NAME OF LICENSING PROGRAM ANALYST: Esther Cortez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/06/2025
LIC809 (FAS) - (06/04)
Page: 3 of 3