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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191201168
Report Date: 08/20/2025
Date Signed: 08/20/2025 02:33:52 PM

Document Has Been Signed on 08/20/2025 02:33 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., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:VILLA SCALABRINI RETIREMENT CENTERFACILITY NUMBER:
191201168
ADMINISTRATOR/
DIRECTOR:		ADILSO LUIZ BALENFACILITY TYPE:
740
ADDRESS:10631 VINEDALE STREETTELEPHONE:
(818) 768-6500
CITY:SUN VALLEYSTATE: CAZIP CODE:
91352
CAPACITY: 130CENSUS: 73DATE:
08/20/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Alicia Avila, Co-Administrator TIME VISIT/
INSPECTION COMPLETED:
01:00 PM
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At approximately 09:30am, Licensing Program Analyst (LPA) Angela Panushkina conducted an unannounced annual visit. LPA met with the Co-Administrator and disclosed the reason for the visit.

At 09:45am LPA and the Co-Administrator toured the facility inside and out.

This is a one-story building with an office, waiting room, one large activity room, conference room, file room, break room, storage rooms and a MedTech room. The waiting area provided hand sanitizer. The main living room has seating and a grand piano for entertainment. There is a reading room and private dining area for family or visitors to use. Facility maintains a comfortable temperature of 72°F. LPA observed postings such as personal rights, building permits, and the facility’s license. The facility is licensed to accommodate 130 non-ambulatory residents of which 16 can be in a memory care unit. The facility also has an approved hospice waiver for a maximum of 8 residents.

At 10:00am, resident rooms were observed to be clean and sanitary. All bedrooms are furnished with beds, dressers and required bedding and linen. The bedrooms have sufficient closet space and sufficient lighting.

The bathrooms were checked for the resident private and shared rooms and the public area of the facility. LPA observed all bathrooms are clean and in good repair and contained fully stocked liquid soap and trash cans. The water temperature was measured between 105.4°F-114.3°F.

The kitchen that prepares all the meals for the facility was observed to be fully stocked with perishable and non-perishable foods.The kitchen work area surface appeared clean, and no food items are stocked with cleaning supplies. Food is restocked regularly at least 2 times a week. The residents with special dietary needs are posted in the kitchen prep area with pictures of the resident and their food choices or required preparation. Continue on LIC809-C

NAME OF LICENSING PROGRAM MANAGER: Nichelle Gillyard
NAME OF LICENSING PROGRAM ANALYST: Angela Panushkina
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 08/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/20/2025
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., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: VILLA SCALABRINI RETIREMENT CENTER
FACILITY NUMBER: 191201168
VISIT DATE: 08/20/2025
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LPA observed seven (7) fire extinguishers throughout the facility which were last services on 08/23/2024. Emergency exit plans were posted in each room and throughout the facility. Emergency exit plan’s had current location and exit routes labeled clearly. All exit paths were free from hazards and obstructions. A fire inspection is conducted every year on the operation of the sprinkler system, electrical panels, water heaters, fire extinguishers, manual pull alarms, carbon monoxide detector and smoke detector. Copy of the inspection report was given to LPA.

LPA observed appropriate outdoor furniture, with a covered shaded area for the residents. LPA discussed the importance of maintaining the care and supervision to meet the needs of residents..

Between 10:30am to 11:30am, LPA reviewed records of ten (10) residents and three (3) staff. Resident and staff records appeared to be complete and updated. Resident’s files contain signed admission agreements and a medical assessment, and all other required documents.

Annual fee is paid in full.
LPA collected Certificate of Liability Insurance, and LIC500.

No citations issued during this visit.
Exit interview conducted and copy of this report signed and delivered.

NAME OF LICENSING PROGRAM MANAGER: Nichelle Gillyard
NAME OF LICENSING PROGRAM ANALYST: Angela Panushkina
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2025
LIC809 (FAS) - (06/04)
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