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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195850275
Report Date: 08/21/2025
Date Signed: 08/21/2025 01:55:44 PM

Document Has Been Signed on 08/21/2025 01:55 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:GAULT HOMEFACILITY NUMBER:
195850275
ADMINISTRATOR/
DIRECTOR:		HASTINGS, SUZIEFACILITY TYPE:
735
ADDRESS:12706 GAULT STREETTELEPHONE:
(818) 759-1252
CITY:NORTH HOLLYWOODSTATE: CAZIP CODE:
91605
CAPACITY: 4CENSUS: 4DATE:
08/21/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:55 AM
MET WITH:Suzie HastingsTIME VISIT/
INSPECTION COMPLETED:
02:00 PM
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Licensing Program Analyst (LPA) Trevor Byrne arrived at the facility unannounced to conduct a required annual visit at 09:55 AM. LPA contacted the facility Administrator Suzie Hastings via telephone call. The Administrator arrived to the facility at 10:13 AM. Entrance interview conducted and the reason for the visit was explained.

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

KITCHEN: 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. Knives and other sharp objects are stored in a locked drawer. The fire extinguisher was observed to be fully charged and last serviced on 05/19/2025.

BEDROOMS: LPA and the Administrator toured four (4) bedrooms at the facility. One (1) bedroom is designated as a staff bedroom and is locked and inaccessible to clients in care. Three (3) client bedrooms were observed, all of which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. One (1) client bedroom is designated as a shared bedroom.

RESTROOMS: LPA observed two (2) common resident restrooms. Both restrooms were observed to be clean. The hot water temperature was measured in both restrooms and was observed to be between 105 and 105.7 degrees Fahrenheit which is within the range required by regulation. Showers were observed to contain non-slip surfaces and mats. Grab bars were observed in both restrooms. Continued on LIC 809C.

NAME OF LICENSING PROGRAM MANAGER: Kasandra Lopez
NAME OF LICENSING PROGRAM ANALYST: Trevor Byrne
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 08/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/21/2025
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: GAULT HOME
FACILITY NUMBER: 195850275
VISIT DATE: 08/21/2025
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COMMON SPACES: This includes the living room, tv room, office, hallway and dining room. The living room furniture was observed to be clean and in good condition. A properly screened fireplace was observed in the living room. The TV room contained a television and activities for resident use. The office was observed to be locked and inaccessible to clients in care. Medications and facility files were observed to be in a locked cabinet located within the hallway near the entrance to the facility. The dining area was observed to be clean and contained adequate seating for resident use. Additionally, the dining room contained all required postings. Fire alarms were tested at 10:40 AM and were functional at the time of the visit.

LAUNDRY: The laundry room contained the facility’s washer and dryer, adequate emergency food and water supplies, and a locked cabinet that was utilized to store cleaning chemicals. A first aid kit was observed and contained all required items.

OUTDOORS: LPA and the facility Administrator toured the outdoor area of the facility. Tables and chairs were observed with appropriate shading. LPA observed two (2) locked sheds to contain tools. The facility has an emergency exit gate that was free from obstruction.

RECORD REVIEW: Record review began at 10:49 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. All staff files contained the required documents and trainings. Four (4) resident files were reviewed. All resident files reviewed contained all required documentation. No deficiencies were observed during record review.

MEDICATION REVIEW / CASH RESOURCE REVIEW: Medication and cash resource review began at 11:55 AM. Medications are stored centrally and securely in a locked cabinet located in the hallway of the facility. Medications for three (3) residents were observed. All medications reviewed were documented properly on their centrally stored medication and destruction record sheet. No deficiencies were observed during medication review. Cash resources were reviewed for two (2) clients, all cash resources observed were documented properly with the corresponding receipts. No deficiencies were observed during cash resource review.

Continued on LIC 809C.

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

DATE: 08/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/21/2025
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: GAULT HOME
FACILITY NUMBER: 195850275
VISIT DATE: 08/21/2025
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INFECTION CONTROL/EMERGENCY DISASTER PLANNING: LPA reviewed the facility’s emergency disaster plan and infection control plan. The facility’s emergency disaster plan is adequate and reviewed annually. The last emergency disaster drill was conducted on 06/10/2025. The facility’s practices as it pertains to infection control are adequate.

INTERVIEWS: During today's visit, LPA interviewed one (1) staff member. The staff member interviewed understood their role and responsibilities, the clients’ rights, the different forms of abuse, and the proper reporting procedures for suspected abuse. LPA was unable to interview clients during today’s inspection due to no clients being present at the time of the inspection.

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

No deficiencies were observed during today’s inspection. Exit interview conducted. A copy of the report was issued.

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

DATE: 08/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/21/2025
LIC809 (FAS) - (06/04)
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