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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195850091
Report Date: 05/24/2024
Date Signed: 05/24/2024 10:55:50 AM


Document Has Been Signed on 05/24/2024 10:55 AM - 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. #250
WOODLAND HILLS, CA 91364



FACILITY NAME:PRESERVE AT WOODLAND HILLS, THEFACILITY NUMBER:
195850091
ADMINISTRATOR:MICHAEL OWENSFACILITY TYPE:
740
ADDRESS:6221 FALLBROOK AVENUETELEPHONE:
(747) 226-5834
CITY:WOODLAND HILLSSTATE: CAZIP CODE:
91367
CAPACITY:60CENSUS: 45DATE:
05/24/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Edie Cano and Michael OwensTIME COMPLETED:
11:00 AM
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Licensing Program Analyst (LPA) Kelly Dulek conducted an unannounced Plan of Correction (POC) visit to this facility to issue a civil penalty for a POC that has not been corrected within the required time frame. LPA arrived at the facility at 09:40AM and met with Business Office Manager (BOM) Edie Cano. Executive Director Michael Owens arrived during the visit. Entrance interview conducted.

LPA Dulek had previously conducted a complaint visit on 05/08/2024 and issued a POC to the facility for not issuing a refund, per the resident's Admission Agreement. During today's visit, LPA spoke with Business Office Manager at 09:43AM, and LPA conducted a brief physical plant tour. BOM reviewed the facility records and indicated there is a check # associated with the refund related to the POC issued and the check was cut on 05/20/2024, however the POC was due on 05/15/2024. Additionally, the check that was cut on 05/20/2024 is in the incorrect amount and there is an additional $561.25 owed.

A civil penalty in the amount of $900 was issued during today's visit. (See LIC 421 dated 05/24/2024, located under the LIC 9099 dated 05/08/2024).

Exit interview was conducted with Business Office Manager and Executive Director. Appeal rights were discussed. A copy of the report was provided.
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly DulekTELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:
DATE: 05/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/24/2024
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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