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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191290890
Report Date: 04/30/2026
Date Signed: 04/30/2026 04:30:50 PM

Document Has Been Signed on 04/30/2026 04:30 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:BLAKE HOMEFACILITY NUMBER:
191290890
ADMINISTRATOR/
DIRECTOR:		SAMUEL BLAKEFACILITY TYPE:
735
ADDRESS:606 JACKMAN AVENUETELEPHONE:
(818) 361-1984
CITY:SAN FERNANDOSTATE: CAZIP CODE:
91340
CAPACITY: 6CENSUS: 6DATE:
04/30/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:15 AM
MET WITH:Jannie Blake - Co AdministratorTIME VISIT/
INSPECTION COMPLETED:
04:30 PM
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Licensing Program Analyst (LPA) Nadia Shahbazian conducted an unannounced Annual Required visit and inspection of the facility. LPA met with Jannie Blake - Co Administrator and explained the reason for the visit. The Adult Residential Facility (ARF) has an approved fire clearance for 6 ambulatory clients; current census is six (6).

At 10:15am, with the assistance of Co-Administrator, LPA took a tour of the physical plant. Required postings were observed in the kitchen and the hallway. The smoke/carbon monoxide detectors are battery operated. The smoke/carbon monoxide detectors were tested and observed to be functioning properly. The fire extinguisher is located in the kitchen and has a charge date of 09/12/2025. Facility conducts quarterly fire/earth quake drills; the last fire/earth quake drill was conducted on 04/01/2026.

Kitchen: LPA observed a refrigerator, stove, microwave oven, dishwasher and laundry machines in the kitchen. Sharp objects were locked in a cabinet in the kitchen and cleaning solutions and detergents were locked under the sink. There is a large supply of dishes in the cabinets. Facility has perishable foods for two (2) days in the refrigerator. A supply of non- perishable foods for seven (7) days were kept in the garage. All kitchen surfaces and appliances were observed to be clean and sanitary. The kitchen has an exit door, leading to the front.

Common Areas: The living room is located near the entry and it leads to the dining area. There is a door in the dining room, leading to the kitchen and there is a sliding door leading to a recreation room. There is a screened, non-functional fireplace in the recreation room, along with games, newspapers, television, cable and internet access. The common areas were properly furnished with ample seating for all residents and staff.

NAME OF LICENSING PROGRAM MANAGER: Mary G Flores
NAME OF LICENSING PROGRAM ANALYST: Nadia Shahbazian
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/30/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/30/2026
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: BLAKE HOME
FACILITY NUMBER: 191290890
VISIT DATE: 04/30/2026
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Bedrooms/Bathrooms: The facility is a two storey house with five (5) bedrooms. There are two (2) bedrooms designated for staff use. One of the staff bedrooms is located on the second floor and has it's own full bathroom but is currently vacant. There are stairs with a chair lift leading to bedroom upstairs. Bedroom #3 is currently a staff room, with it's own bathroom. Bedroom #3 includes a small office area with locked cabinets for maintaining client and staff records. There are three (3) shared bedrooms for client use. All bedrooms contained chairs, night stands, dresser drawers, lamps, and adequate bedding. There is a full bathroom at the end of the hallway, which is utilized by clients. LPA observed grab bars and non-skid mat in the bathroom. The water temperature at the client bathroom was measured at 115.0 degrees Fahrenheit.

Surrounding Grounds: The front entry door is used as the main emergency exit. In addition the facility has an exit door in the kitchen and a door in the recreation room, leading to the backyard. All walkways and exit passages were free of obstruction. There is a covered patio with ample furniture appropriate for outdoor


use. No bodies of water were observed. There is an attached garage, currently used as storage. LPA observed two freezers and a refrigerator in the garage, with ample supply of perishable foods.

Resident Files: LPA conducted a file review of resident records to ensure compliance of licensing forms.
5 out of 6 clients did not have current physician reports, a citation will be provided.

Staff Files: LPA conducted a file review of staff records to ensure forms and training are up to date and compliant with licensing forms.

Medications: A locked cabinet in the kitchen contained the medications and the first aid kit and manual. Medication Records for all 6 clients were reviewed for proper documentation and administration.

Pursuant to Title 22 Division 6 of the CA Code of Regulations, deficiencies observed and cited on 809-D.

Exit Interview Conducted. Appeal rights and a Copy of the Report provided.

NAME OF LICENSING PROGRAM MANAGER: Mary G Flores
NAME OF LICENSING PROGRAM ANALYST: Nadia Shahbazian
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/30/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/30/2026
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/30/2026 04:30 PM - It Cannot Be Edited


Created By: Nadia Shahbazian On 04/30/2026 at 03:51 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., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: BLAKE HOME
FACILITY NUMBER: 191290890

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/30/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1507(b)
(B) The client's individualized health care plan shall be reassessed at least every 12 months or more frequently as determined by the client's physician or nurse practitioner during the time the client receives incidental medical services in the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in not having current physician recocords for 5 out of 6 clients, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/15/2026
Plan of Correction
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Administrator will obtain copies of physician records for 5 clients and will submit to LPA by the POC date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
Mary G Flores
NAME OF LICENSING PROGRAM MANAGER:
Nadia Shahbazian
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/30/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/30/2026


LIC809 (FAS) - (06/04)
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