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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195850239
Report Date: 05/06/2025
Date Signed: 05/06/2025 05:09:17 PM

Document Has Been Signed on 05/06/2025 05:09 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:SILVER LIGHT CAREFACILITY NUMBER:
195850239
ADMINISTRATOR/
DIRECTOR:		KHACHATRYAN, ELBAFACILITY TYPE:
740
ADDRESS:8201 VANTAGE AVENUETELEPHONE:
(747) 228-4111
CITY:NORTH HOLLYWOODSTATE: CAZIP CODE:
91605
CAPACITY: 6CENSUS: 6DATE:
05/06/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:01 AM
MET WITH:Elba KhachatryanTIME VISIT/
INSPECTION COMPLETED:
05:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Trevor Byrne arrived at the facility unannounced to conduct a required annual visit at 10:01 AM. LPA met with facility staff who contacted the facility Administrator Elba Khachatryan. The Administrator arrived to the facility at 10:25 AM. Entrance interview conducted and the reason for the visit was explained.

Beginning at 10:15 AM the LPA, along with facility staff and the Administrator toured the physical plant areas inside and outside to ensure there are no health and safety hazards and that facility is in compliance with Title 22 Regulations. The following was observed:

KITCHEN: The LPA observed the kitchen area to be clean. Kitchen appliances appeared to be in operable condition. The facility has a sufficient supply of two (2) days perishable and seven (7) days non-perishable food. At 10:20 AM LPA observed an un-secured cabinet located above the facility fridge to contain knives and other sharp objects. Administrator placed a locking device on the cabinet during the visit. LPA observed a fire extinguisher mounted on the wall to be purchased on 04/13/2024. At 10:24 AM LPA observed an unsecured under-sink cabinet in the kitchen to contain cleaning chemicals including glass cleaner and Clorox bleach wipes. The Administrator installed a locking device at the time of the visit.

Continued on LIC 809C.
NAME OF LICENSING PROGRAM MANAGER: Kasandra Lopez
NAME OF LICENSING PROGRAM ANALYST: Trevor Byrne
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/06/2025
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 N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: SILVER LIGHT CARE
FACILITY NUMBER: 195850239
VISIT DATE: 05/06/2025
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COMMON AREAS: This includes the living room, hallway, and dining area. LPA observed the living room to be clean and properly furnished at the time of the visit. The living room contained an infection control point and all required postings. The hallway was observed to contain a locked storage closet which contained extra care supplies and PPE supplies. The dining area was observed to contain a fireplace, it is appropriately screened and contains no tools. Additionally, the dining area was observed to be equipped with adequate seating for resident use. All furniture throughout the facility was observed to be clean and in good repair. The facility’s combination fire and carbon monoxide alarms were tested at 01:46 PM and were functional at the time of the visit.

BEDROOMS: There are three (3) bedrooms in the facility; all three (3) are dual occupancy resident rooms. LPA and facility Administrator toured all three (3) resident bedrooms. All resident rooms were observed to be furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting. Bedroom #3 contains a direct exit to the outdoors of the facility.

BATHROOMS: There are two (2) bathrooms at the facility. Both are designated as shared/common resident bathrooms. All resident bathrooms were observed to be clean and were equipped with nonskid surfaces. Grab bars were observed in all resident showers and near all resident toilets. LPA observed one (1) shower grab bar located in the non-ambulatory resident bathroom to be improperly secured to the wall. LPA informed the Administrator who agreed to perform needed repairs to the grab bar. The water temperature was measured to be between 117.6 and 114.6 degrees Fahrenheit, which is in compliance with regulation.

OUTDOOR SPACE: The facility has two (2) emergency exit gates located on either side of the facility; LPA observed clear passageways for emergency exit use. The facility has adequate shaded seating outdoors for resident use. LPA observed the backyard to contain a pool. It was appropriately fenced off and made inaccessible to clients in care. LPA observed all railings to be sturdy and appropriately secured.

Continued on LIC 809C.
NAME OF LICENSING PROGRAM MANAGER: Kasandra Lopez
NAME OF LICENSING PROGRAM ANALYST: Trevor Byrne
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2025
LIC809 (FAS) - (06/04)
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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 N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: SILVER LIGHT CARE
FACILITY NUMBER: 195850239
VISIT DATE: 05/06/2025
NARRATIVE
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GARAGE: LPA observed the garage to be un-locked and accessible to clients in care. LPA observed the garage to contain the facility’s washer and dryer, adequate emergency food and water supplies, and an extra refrigerator. At 10:51 AM LPA observed the garage to contain unsecured cleaning chemicals, laundry chemicals, and tools including a saw. LPA informed the Administrator of the unsecured items. The Administrator agreed to secure the items into a locked storage. LPA advised the Administrator that they were previously cited for a violation of CCR 87309(a) on 10/22/2024 and 03/01/2025. LPA advised Administrator that a civil penalty in the amount of $250 will be assessed on today's date (05/06/2025) due to a repeat violation of the same regulation within a 12-month period.

RECORD REVIEW: Record review began at 11:05 AM. Staff and resident records were reviewed for documents including, but not limited to: health screening, TB test, staff training records, fingerprint clearance, resident physician's report, needs and service appraisal, consent forms, and personal rights. Four (4) staff files were reviewed. Three (3) staff files were observed to contain incomplete LIC 501 forms and were missing information including the employee’s home address, educational background, past experience, including types of employment and former employers, type of position for which employed, termination date, and reasons for leaving. Additionally, LPA observed one (1) employee to be missing proof of a negative TB test. LPA informed the Administrator who agreed to have the identified employees fill in the missing information and agreed to obtain proof of a negative TB test for the identified employee. LPA observed staff #1 (S1) to be assisting in distributing resident medications at the time of the visit. LPA observed the training records for S1. LPA did not observe documentation of S1 completing medication assistance training. LPA informed the Administrator who stated that classes were given by a nurse. The Administrator was unable to provide LPA with proof of course completion at the time of the visit. Continued on LIC 809C.
NAME OF LICENSING PROGRAM MANAGER: Kasandra Lopez
NAME OF LICENSING PROGRAM ANALYST: Trevor Byrne
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2025
LIC809 (FAS) - (06/04)
Page: 4 of 11
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: SILVER LIGHT CARE
FACILITY NUMBER: 195850239
VISIT DATE: 05/06/2025
NARRATIVE
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RECORD REVIEW CONTINUED: Six (6) resident files were reviewed. Three (3) resident files were observed to have their admission agreements missing the amounts charged for basic services. LPA informed the Administrator who amended the admission agreements with the correct amounts charged and obtained resident’s signatures confirming the correct amount during the visit. LPA observed one (1) resident's file to contain two (2) incident reports dated 01/22/2025 and 04/19/2025. LPA reviewed the facility's e-file and the LPA's in-box for proof of the submitted incident reports. LPA did not observe the incident reports in either location. LPA asked the Administrator if the reports were submitted to licensing. The Administrator stated that they believe they were but the Administrator was unable to provide proof of submittal at the time of the inspection. LPA reminded the Administrator that all incident reports must be submitted to licensing no later than seven (7) days following the incident.

MEDICATION REVIEW: Medication review began at 01:14 PM. Medications for three (3) of six (6) residents were observed. LPA observed two (2) resident’s centrally stored medication and destruction record sheets (CSMDRs) to contain out of date information including prescription numbers and the dates the medications were started. Additionally, LPA observed one (1) resident medication to not be listed on the resident’s CSMDR. LPA informed the Administrator who agreed to update the identified resident’s CSMDRs with accurate medications and other required information.

INFECTION CONTROL/EMERGENCY DISASTER PLANNING: During today’s visit, the LPA reviewed the
facility's infection control practices and the facility's emergency disaster plan. The facility’s policies and procedures as it pertains to infection control are adequate. Emergency disaster drills are conducted quarterly; the facility’s last emergency disaster drill was conducted on 04/26/2025. The facility’s emergency disaster plan is up to date and is adequate. Both the infection control plan and the emergency disaster plan are reviewed/updated annually by the facility’s Administrator.

Continued on LIC 809C.
NAME OF LICENSING PROGRAM MANAGER: Kasandra Lopez
NAME OF LICENSING PROGRAM ANALYST: Trevor Byrne
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2025
LIC809 (FAS) - (06/04)
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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 N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: SILVER LIGHT CARE
FACILITY NUMBER: 195850239
VISIT DATE: 05/06/2025
NARRATIVE
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INTERVIEWS: LPA interviewed two (2) residents. Both residents interviewed stated that the staff treat them well and are attentive to their needs. No residents interviewed had concerns with the facility. LPA interviewed one (1) staff member with the assistance of the Administrator acting as a translator. The staff member interviewed was knowledgeable on their roles and responsibilities, the resident’s rights, the forms of abuse, and the appropriate reporting procedures for suspected abuse.

During today’s visit LPA obtained a copy of the facility’s LIC 500, resident roster, and current liability insurance.

Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies and civil penalty were cited (refer to LIC 809-D): Exit interview conducted and copy of the report was issued and appeal rights provided.

NAME OF LICENSING PROGRAM MANAGER: Kasandra Lopez
NAME OF LICENSING PROGRAM ANALYST: Trevor Byrne
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2025
LIC809 (FAS) - (06/04)
Page: 6 of 11
Document Has Been Signed on 05/06/2025 05:09 PM - It Cannot Be Edited


Created By: Trevor Byrne On 05/06/2025 at 03:39 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: SILVER LIGHT CARE
FACILITY NUMBER: 195850239

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/06/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space and Access
(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above as knives and cleaning solutions in the kitchen in addition to chemicals and tools in the garage were left in unsecured storage spaces which poses an immediate safety risk to persons in care.
POC Due Date: 05/07/2025
Plan of Correction
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Licensee agreed to submit proof of appropriate secured storage for the identified items no later than POC due 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.
Kasandra Lopez
NAME OF LICENSING PROGRAM MANAGER:
Trevor Byrne
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/06/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/06/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/06/2025 05:09 PM - It Cannot Be Edited


Created By: Trevor Byrne On 05/06/2025 at 03:39 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: SILVER LIGHT CARE
FACILITY NUMBER: 195850239

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/06/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(e)(4)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (4) Grab bars shall be maintained for each toilet, bathtub and shower used by residents.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above as one grab bar in the non-ambulatory resident bathroom was observed to be loose from the wall and not appropriately secured which poses a potential safety risk to persons in care.
POC Due Date: 05/20/2025
Plan of Correction
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Administrator agreed that Licensee will submit proof of appropriate repairs to CCLD no nater than POC due date.
Type B
Section Cited
CCR
87412(a)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:

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 as three (3) employee file's LIC 501's were observed to be missing information including: Home address, Educational background, Past experience, including types of employment and former employers, Type of position for which employed, Termination date, and Reasons for leaving. Which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/20/2025
Plan of Correction
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Administrator agreed that Licensee will submit proof of completed LIC 501 forms for the identified employees no later than POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Kasandra Lopez
NAME OF LICENSING PROGRAM MANAGER:
Trevor Byrne
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/06/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/06/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/06/2025 05:09 PM - It Cannot Be Edited


Created By: Trevor Byrne On 05/06/2025 at 03:39 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: SILVER LIGHT CARE
FACILITY NUMBER: 195850239

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/06/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.69(a)(2)
Other Provisions
(a) Each residential care facility for the elderly licensed under this chapter shall ensure that each employee of the facility who assists residents with the self-administration of medications meets all of the following training requirements: (2) In facilities licensed to provide care for 15 or fewer persons, the employee shall complete 10 hours of initial training. This training shall consist of 6 hours of hands-on shadowing training, which shall be completed prior to assisting with the self-administration of medications, and 4 hours of other training or instruction, as described in subdivision (f), which shall be completed within the first two weeks of employment.

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 as one employee did not have proof of completed medication administration training which poses a potential health risk to persons in care.
POC Due Date: 05/20/2025
Plan of Correction
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Administrator agreed that Licensee will submit proof of completed medication trainings for the identified employee no later than POC due date.
Section Cited
Deficient Practice Statement
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3
4
POC Due Date:
Plan of Correction
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4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Kasandra Lopez
NAME OF LICENSING PROGRAM MANAGER:
Trevor Byrne
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/06/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/06/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/06/2025 05:09 PM - It Cannot Be Edited


Created By: Trevor Byrne On 05/06/2025 at 03:49 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: SILVER LIGHT CARE
FACILITY NUMBER: 195850239

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/06/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(f)
87411 Personnel Requirements - General

(f) All personnel, including the licensee and administrator, shall be in good health...Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure....

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 as one employee did not have proof of a negative TB test which poses a potential health risk to persons in care.
POC Due Date: 05/20/2025
Plan of Correction
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Administrator agreed that licensee will submit proof of a negative TB test for the identified employee no later than POC due date.
Type B
Section Cited
CCR
87465(h)(6)
87465 Incidental Medical and Dental Care
(h) The following requirements shall apply to medications which are centrally stored:
(6) The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least one year and includes:

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on record review, the licensee did not comply with the section cited above as one resident's CSMDR contained incorrect perscription numbers, dates filled, and dates started. Additionally, one resident's medication was not accurately logged on their CSMDR which poses a potential health risk to persons in care.
POC Due Date: 05/20/2025
Plan of Correction
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Administrator agreed that licensee will submit proof of accurate CSMDR sheets for the two identified residents no later than POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Kasandra Lopez
NAME OF LICENSING PROGRAM MANAGER:
Trevor Byrne
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/06/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/06/2025


LIC809 (FAS) - (06/04)
Page: 10 of 11
Document Has Been Signed on 05/06/2025 05:09 PM - It Cannot Be Edited


Created By: Trevor Byrne On 05/06/2025 at 03:56 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: SILVER LIGHT CARE
FACILITY NUMBER: 195850239

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/06/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87507(g)(3)(A)
87507 Admission Agreements
(g) Admission agreements shall specify the following:
(3) Payment provisions, including the following:
(A) Rate for all basic services which the facility is required to provide in order to obtain and maintain a license. Basic services rate(s), including:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above as three resident admission agreements were observed to be missing the rates charged for basic services which poses a potential personal rights risk to persons in care.
POC Due Date: 05/06/2025
Plan of Correction
1
2
3
4
Administrator entered the correct amounts charged at the time of the visit and obtained resident signatures confirming the ammounts listed. POC cleared.
Type B
Section Cited
CCR
87211(a)(1)
87211 Reporting Requirements
(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following:
(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events...

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above as LPA observed one resident's file to contain two incident reports that LPA and the Administrator were unable to find proof that they were submitted to licensing within the appropriate timeframe which poses a potential safety or personal rights risk to persons in care.
POC Due Date: 05/20/2025
Plan of Correction
1
2
3
4
Administrator agreed that licensee will submit a statement of understanding confirming that they understand the importance of submitting incident reports within the required timeframe.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Kasandra Lopez
NAME OF LICENSING PROGRAM MANAGER:
Trevor Byrne
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/06/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/06/2025


LIC809 (FAS) - (06/04)
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