<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195850339
Report Date: 08/12/2025
Date Signed: 08/12/2025 05:59:19 PM

Document Has Been Signed on 08/12/2025 05:59 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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:INN AT THE PARK VENTURAFACILITY NUMBER:
195850339
ADMINISTRATOR/
DIRECTOR:		ANGUIANO, ROSEFACILITY TYPE:
740
ADDRESS:21200 VENTURA BLVDTELEPHONE:
(818) 884-7100
CITY:WOODLAND HILLSSTATE: CAZIP CODE:
91364
CAPACITY: 200CENSUS: 149DATE:
08/12/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:45 AM
MET WITH:Rose AnguianoTIME VISIT/
INSPECTION COMPLETED:
04:45 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analysts (LPA) Zabel Chochian conduct a required annual visit at this facility.

Upon arrival, the LPA was greeted by staff and also the Administrator, Rose Anguiano. Reason for the visit was stated. Entrance interview conducted with Administrator. LPA confirmed that the facility is operating according to the original facility plan of operation submitted and no changes have been made since licensure. Administrator acknowledged understanding that no changes can be made to the facility plan of operation unless it is approved by LPA/the department. - following updated records request were requested and obtained: facility residents and staff roster; fire and smoke alarm tests; dieticians report; facility's current liability insurance; Emergency and disaster plan.

LPA, staff and the Administrator toured the physical plant areas inside and outside to ensure facility is in compliance with Title 22 Regulations from approximately 10:45am-12:45pm. COMMON AREAS: At the time of the visit, furniture in the common areas were observed to be in good condition. The facility maintained a comfortable temperature. Smoke detector(s) and carbon monoxide detectors are tested and maintain operational. The fire extinguishers observed fully charged and were last serviced 01/23/2025. The LPA observed required postings throughout the common space. The LPA observed five (5) stairwells; each have an emergency evacuation chair on the 2nd floor. RESIDENT BEDROOMS & RESTROOMS: The LPA observed the resident bedrooms, which were furnished appropriately with linens, appropriate furnishings, and sufficient lighting. At approximately 11:22am, Room 110 floor observed discolored; room 107 restroom cabinet in disrepair (not closing properly); room 212, window shades not closing and non skid strips peeling off in bath tub; room 215 missing screen and torn shower curtain; room 259, window shades missing; (inactive) wiring observed in the bathroom near the wall and towel rack; room 263, shower head not secured to wall; room 272, no hot water; no window shades; night stand drawer observed broken; Memory care common shower room shower head needs to be secured to the wall. (Continue to LIC809c).

NAME OF LICENSING PROGRAM MANAGER: Desaree Perera
NAME OF LICENSING PROGRAM ANALYST: Zabel Chochian
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 08/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/12/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 5
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)
Page: 2 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: INN AT THE PARK VENTURA
FACILITY NUMBER: 195850339
VISIT DATE: 08/12/2025
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Resident restrooms observed stocked with sufficient supply of toiletries; towels and hygiene items for each resident (towels and wash clothes are not shared). Restrooms observed with grab bars and non-skid surfaces.

KITCHEN: The kitchen/food service area and emergency food/water supply was checked at approximately 1pm-1:45pm; Knives are stored and inaccessible to residents. Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable items for at least 2 days and non-perishable food items for at least 7 days. Facility also has an emergency food and water supply which is rotated out accordingly.

INFECTION CONTROL: The facility has an adequate supply of Personal Protection Equipment (PPE), and is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of an infectious disease. According to Administrator and staff the facility infection control policy and procedures are followed accordingly.

MEDICATIONS: Medications reviewed from approximately 2pm-3pm. The medications are centrally stored in the medication room on the first floor. Medications are labeled and stored inaccessible. Random sample of (four) 4 residents medications reviewed revealed that staff are not properly documenting the expiration and fill dates on the centrally stored medication and destruction log/record. Also the preprinted centrally stored medication records that the facility receives from the pharmacy observed with inaccurate expiration dates recorded on the centrally stored log/record.

Due to time constraints the annual inspection will continue to a later date. LPA will return at a later date to review resident records, staff files and training records.

The following deficiencies observed during today's visit are cited (see 809D) from the California Code of Regulations, Title 22 and California Health and Safety Code.

Exit interview conducted. A copy of the report and appeal rights were issued.

NAME OF LICENSING PROGRAM MANAGER: Desaree Perera
NAME OF LICENSING PROGRAM ANALYST: Zabel Chochian
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2025
LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 08/12/2025 05:59 PM - It Cannot Be Edited


Created By: Zabel Chochian On 08/12/2025 at 04:19 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: INN AT THE PARK VENTURA
FACILITY NUMBER: 195850339

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/12/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(e)(5)(A)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (5) Slip-resistant mats, strips, or flooring shall be used in all bathtub and shower floors. (A) All slip-resistant mats, strips, or flooring shall be in good repair and maintain slip-resistant properties.

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. Resident shower floor strips observed peeling off in rooms 212,and 215. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/19/2025
Plan of Correction
1
2
3
4
Administrator agreed to have maintenance apply new strips and check all resident bathroom shower floors to ensure the floor strips are in place or provide shower mats. Submit photos and self certification letter that all other bathrooms are checked to confirm showers/tub strips or shower mats are in place.
Type B
Section Cited
CCR
87303(e)(6)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (6) Toilet, handwashing and bathing facilities shall be maintained in operating condition. Additional equipment shall be provided in facilities accommodating physically handicapped and/or nonambulatory residents, based on the residents' needs.

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 . Room 271 bathroom sink faucet is out of service (water leak); room 272 bathroom faucett does not supply sufficent hot water. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/19/2025
Plan of Correction
1
2
3
4
Administrator agreed to have facility mainenance contact a plumber for maintenance and repair. Submit proof of invoice for repairs made to ensure plumbng issues resolved for room 272 and 271.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Desaree Perera
NAME OF LICENSING PROGRAM MANAGER:
Zabel Chochian
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/12/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/12/2025


LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 08/12/2025 05:59 PM - It Cannot Be Edited


Created By: Zabel Chochian On 08/12/2025 at 04:19 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: INN AT THE PARK VENTURA
FACILITY NUMBER: 195850339

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/12/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(h)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview and record review, the licensee did not comply with the section cited above. Four out of four resident medication records reviewed revealed record keeping issues (inaccurate expiration and fill dates recorded on the centrally stored records by facility staff and the prefilled centrally stored records provided by the pharmacy. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/19/2025
Plan of Correction
1
2
3
4
Administrator and staff reviewed and corrected the errors during the visit; Administrator contacted the pharmacy to inform them of the errors. Administrator agreed to coordinate an in services training with staff on policy and procedures pertaining to medication record keeping.
Type B
Section Cited
CCR
87303(a)
87303 (a) Maintenance and Operation: (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

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. Room 110 flooring needs to be painted or repaired. Memory care resident restroom shower/bath tubs (room 259, 263, 271,272) need to be maintained clean and sanitary.
POC Due Date: 08/19/2025
Plan of Correction
1
2
3
4
Administrator agreed to have maintenance and housekeeping clean and maintain memory care unit shower/bath tubs clean and sanitary. Submit photos and self certification letter that all memory care unit shower/bath tubs are checked and maintained clean and sanitary.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Desaree Perera
NAME OF LICENSING PROGRAM MANAGER:
Zabel Chochian
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/12/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/12/2025


LIC809 (FAS) - (06/04)
Page: 5 of 5