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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 567610056
Report Date: 01/16/2025
Date Signed: 01/16/2025 01:35:45 PM

Document Has Been Signed on 01/16/2025 01:35 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:APPLEGATE @ BERKSHIREFACILITY NUMBER:
567610056
ADMINISTRATOR/
DIRECTOR:		ALVAREZ, CYNTHIAFACILITY TYPE:
740
ADDRESS:2010 FULLBROKE DRIVETELEPHONE:
(805) 870-4400
CITY:THOUSAND OAKSSTATE: CAZIP CODE:
91362
CAPACITY: 6CENSUS: 6DATE:
01/16/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:32 AM
MET WITH:Irma CarmonaTIME VISIT/
INSPECTION COMPLETED:
01:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Angela Barutyan conducted a Case Management - Deficiencies visit in conjunction with a complaint visit (Complaint Control #29-AS-20250113113032). The purpose of the visit is to issue a citation for a deficiency observed during the initial complaint investigation.

During the visit on 01/16/2025, LPA reviewed three (3) personnel files and observed Staff #1’s (S1) file missing 20 hours annual training for 2024. S1 does not handle medications and interviews with staff, residents, and Licensee Irma Carmona confirmed that S1 does not administer or prepare medications. However, S1 was missing annual training for subjects including, but not limited to: dementia, aging, food preparation, and residents rights. Licensee stated they will create a training schedule for S1 to complete their 20 hours of annual training. The remaining two (2) personnel files observed were in order and had no missing documents or training.

The following deficiency was observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22. Administrator was informed that failure to correct deficiency may result in civil penalties.

Exit interview was conducted. A copy of the report and appeal rights were provided.

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Angela Barutyan
LICENSING EVALUATOR SIGNATURE: DATE: 01/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/16/2025
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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Document Has Been Signed on 01/16/2025 01:35 PM - It Cannot Be Edited


Created By: Angela Barutyan On 01/16/2025 at 12:38 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: APPLEGATE @ BERKSHIRE
FACILITY NUMBER: 567610056

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/16/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/30/2025
Section Cited
CCR
87411(c)

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87411 Personnel Requirements - General
(c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69
This requirement is not met as evidenced by:
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Licensee agreed to create a training plan for S1's 20 hours of annual training and send proof of the plan to CCL by 01/30/2025.
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Based on record review, the licensee did not comply with the section cited above as Staff #1 (S1) was missing 20 hours of annual training which poses a potential health, safety, or personal rights risk to persons in care.
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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.
SUPERVISOR'S NAME:Kristin Heffernan
LICENSING EVALUATOR NAME:Angela Barutyan
LICENSING EVALUATOR SIGNATURE:
DATE: 01/16/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/16/2025


LIC809 (FAS) - (06/04)
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