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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191220673
Report Date: 08/13/2025
Date Signed: 08/13/2025 03:25:54 PM

Document Has Been Signed on 08/13/2025 03:25 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 S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:ROBINSON MANOR IIFACILITY NUMBER:
191220673
ADMINISTRATOR/
DIRECTOR:		RETHA DE JOHNETTEFACILITY TYPE:
735
ADDRESS:628 ROYCE STREETTELEPHONE:
(626) 791-2486
CITY:ALTADENASTATE: CAZIP CODE:
91001
CAPACITY: 10CENSUS: 9DATE:
08/13/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:35 AM
MET WITH:Administrator, Retha De JohnettaTIME VISIT/
INSPECTION COMPLETED:
03:40 PM
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Licensing Program Analyst (LPA) Antonia Alvizar-Ettima conducted an unannounced Required 1-Year visit to this facility. LPA met with Administrator and gained entry and discussed the purpose of this visit.

During the tour, LPA observed that the facility is a single- story home located in a residential community. The facility is an Adult Residential Facility (ARF). At about 9:55am, LPA Antonia Alvizar-Ettima and Administrator conducted a tour of physical plant inside and out. The facility consists of a living and dining room, kitchen and five (5) bedrooms and (3) three bathrooms. Two (2) bedrooms are double occupancy are used for male clients. Two (2) bedrooms are double occupancy and one (1) private bedroom are used for female clients. One (1) full size restroom is used for male clients and two (2) full size restrooms are used for female clients. Facility current census is nine (9) clients.

During Eaton Fire Emergency procedures, the facility was approved for capacity waiver, to bring 4 male residents from the Robinson’s Manor (Facility # 191229547) due to burning to the ground. However, after the emergency evacuation was lifted the facility was notified that they need to decrease the capacity from ten (10) to six (6) clients or original census. The Administrator was reminded that at the time of this visit the facility is operating over capacity and the licensee must make corrections as soon as possible. During visit seven (7) clients are attending Day Program, one (1) client was out in the community and one (1) client was at facility and interviewed by the LPA. Common areas were clean and appropriately furnished.

LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:

Cont. on LIC809-C

NAME OF LICENSING PROGRAM MANAGER: Naira Margaryan
NAME OF LICENSING PROGRAM ANALYST: Antonia Alvizar-Ettima
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 08/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/13/2025
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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: ROBINSON MANOR II
FACILITY NUMBER: 191220673
VISIT DATE: 08/13/2025
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Kitchen area was clean and hazardous items (knifes, other sharp items, toxins and other chemicals) were properly secured. An adequate supply of perishable and non-perishable foods was observed to be properly stored on site.

The laundry room was located to the left from the kitchen. LPA Antonia Alvizar-Ettima observed washer and dryer, both were functional.

All client bedrooms were sufficiently furnished for double occupancy, fixtures worked and no hazards were observed. Bathrooms were sanitary, the hot water was tested between 106.3 -117.1*F.

The facility also contains an outdoor area, consisting of a patio, garden, garage and cottage building. No hazardous items were observed in the yard and garage. The garage is used to store a second refrigerator with food, extra dippers and Personal Protective Equipment (PPE). The cottage building is occupied by living staff. LPA observed build in ramps in front of facility and in the backyard which was built for the emergency exit to the passage way, that leads to the front of the facility. LPA reviewed clients medication supply and medication administration records. No discrepancies were noted. All smoke detectors were functional. Fire extinguishers were fully charged, and the facility's last Fire/Evacuation drill was conducted on 07/24/2025.

LPA reviewed client files. The files observed to contain signed admission agreements, identifying information, medical assessment, personal rights, need and services appraisals, psychiatric evaluation report, consent forms, personal and incidental fund logs, inventory sheet for personal items and valuables, and other documents as required by the Licensing Office and Regional Center.

LPA reviewed the staff files. The records contained, personal requirements/job applications; health screenings and criminal record clearances, Administrator Certificated, First Aid/CPR Certificates were current, and all training records were present.

No immediate health and safety hazard is noted during this visit.

Exit interview was conducted, a copy of report was issued.

NAME OF LICENSING PROGRAM MANAGER: Naira Margaryan
NAME OF LICENSING PROGRAM ANALYST: Antonia Alvizar-Ettima
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2025
LIC809 (FAS) - (06/04)
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