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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195850376
Report Date: 01/28/2026
Date Signed: 01/28/2026 09:05:24 PM

Document Has Been Signed on 01/28/2026 09:05 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:EMPOWER RESIDENTIAL WELLNESS CENTER LLCFACILITY NUMBER:
195850376
ADMINISTRATOR/
DIRECTOR:		DAHLMANN, MARIAFACILITY TYPE:
772
ADDRESS:6603 BELLINGHAM AVETELEPHONE:
(818) 209-5011
CITY:NORTH HOLLYWOODSTATE: CAZIP CODE:
91606
CAPACITY: 6CENSUS: 2DATE:
01/28/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:21 AM
MET WITH:Maria Dahlamn, AdministratorTIME VISIT/
INSPECTION COMPLETED:
09:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Christine Yee conducted an unannounced required Annual Inspection and used the CARE Inspection Tool to conduct the visit. Upon arrival, LPA Yee was let into the home by Aprille Ross. Maria Dahlmann was contacted by Staff and she joined the visit at 11:09am. The reason for today's visit was provided. Gurveen Bal, Therapist arrived in the afternoon to conduct the rest of the visit.

The facility is a single storey family home consisting of a dining room, Living room, a kitchen, a family room, four bedrooms of which one is designated as an office, a common bathroom and a private bathroom located in the bedroom identified as room #4. Located in the back is a separate building with a separate address of 12207 Kittridge Street and is not part of the facility. No bodies of water observed on the property. The facility is fire cleared for 6 AMBULATORY clients.

On today's visit all 11 domains of the CARE Inspection Tool was reviewed. Also reviewed on today's visit were 2 client files and 6 staff files. A tour of the facility, inside and outside was conducted.
The following was observed on today's visit:
  • The living room, dining room, kitchen and family room were all appropriately furnished for it's designated use.
  • Bedroom #1, Bedroom #2 and Bedroom #4 were all observed with 2 beds each, 2 chairs, 2 night stands, 2 dressers and built in closets.
  • The common and private bathroom were both equipped with a shower stall, a sink and a toilet. Slip resistant mats were observed in the shower stalls. Water temperature tested in the common bathroom read 127.2 degrees Fahrenheit and the water in the private bathroom read 127.1 degrees Fahrenheit.
NAME OF LICENSING PROGRAM MANAGER: Kristin Heffernan
NAME OF LICENSING PROGRAM ANALYST: Christine Yee
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 01/28/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/28/2026
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 N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: EMPOWER RESIDENTIAL WELLNESS CENTER LLC
FACILITY NUMBER: 195850376
VISIT DATE: 01/28/2026
NARRATIVE
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  • fire extinguishers were observed in the family room and dining room. They were last serviced on 10/24/25.
  • The hardwired smoke detectors located in the resident rooms and office and the combination smoke/carbon monoxide detectors located in bedroom #4, family room and the resident hallway were tested and were operational.
  • per review of the food supply, there was sufficient perishable foods for a minimum of 2 days and insufficient non-perishable foods for a minimum of 7 days maintained on the premises.
  • 6 sets of bed linens, 12 bath towels, 12 hand towels, 6 blankets were observed in the linen closet. No face towels were observed.
  • Per file review, the facility does not have PRN Authorization letters on file for Resident #1 and Resident #2's PRN medications noted on the medication list
  • The facility stores and handles clients funds and does not have a surety bond.
  • Medications are stored in the locked office.
  • Cleaning solutions are locked in the office and in the laundry room.
  • The inside and outside areas were toured and were observed to be clean.


Deficiencies cited under California Code of Regulations, Title 22, Division 6, Chapter 2. Civil Penalties were assessed.

Exit interview was conducted, Appeals rights were discussed and a copy was given.
NAME OF LICENSING PROGRAM MANAGER: Kristin Heffernan
NAME OF LICENSING PROGRAM ANALYST: Christine Yee
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 01/28/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/28/2026
LIC809 (FAS) - (06/04)
Page: 3 of 8
Document Has Been Signed on 01/28/2026 09:05 PM - It Cannot Be Edited


Created By: Christine Yee On 01/28/2026 at 07:21 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: EMPOWER RESIDENTIAL WELLNESS CENTER LLC
FACILITY NUMBER: 195850376

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/28/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
81088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

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 the water tested in the common bathroom read 127.2 and private bathroom read 127.1 degrees Fahrenheit, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/29/2026
Plan of Correction
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The Licensee will adjust the water heater themostat to ensure that the water temperature attains a temperature that is within Title 22 requirements of 105 - 120 degrees Fahrehheit. Licensee will provide evidence that the water temperature is within Titlle 22 ranfe by 1/29/26.
Type A
Section Cited
CCR
81019(e)(3)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code section 1522 shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 81019(f); or

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 Travis Takamori and Gurveen Bal have criminal record clearances but a criminal record transfer was not requested to associate the 2 staff to the facility which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/29/2026
Plan of Correction
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The Licensee will read Title 22, Section 81019 and submit a written statement that the section was read and understood and how the facility will ensure that all staff who have received a criminal record clearance, also has been associated to the facility prior to being present at the facility by 1/29/26. Also provide evidence that T. Takamori and G. Bal have requested a criminal record transfer by 1/29/26
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Kristin Heffernan
NAME OF LICENSING PROGRAM MANAGER:
Christine Yee
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 01/28/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/28/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/28/2026 09:05 PM - It Cannot Be Edited


Created By: Christine Yee On 01/28/2026 at 07:21 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: EMPOWER RESIDENTIAL WELLNESS CENTER LLC
FACILITY NUMBER: 195850376

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/28/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
81088(i)(4)(A)
Fixtures, Furniture, Equipment, and Supplies
(i) The licensee shall ensure provision to each client of the following furniture, equipment and supplies necessary for personal care and maintenance of personal hygiene. (4) Clean linen in good repair, including lightweight, warm blankets and bedspreads; top and bottom bed sheets; pillow cases; mattress pads; rubber or plastic sheeting, when necessary; and bath towels, hand towels, and washcloths. (A) The quantity of linen provided shall permit changing the linen at least once each week or more often when necessary to ensure that clean linen is in use by clients at all times.

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 there were no hand towels available for client use ] which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/04/2026
Plan of Correction
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The Licensee will review the bed linens and bath towels to ensure that there is sufficient bed linens and bath towels available to allow for weekly changing or as needed. Provide evidence that the hand towels have been purchased in quantities to allow for changing by 2/4/26
Type B
Section Cited
CCR
81075(b)(5)
Health-Related Services
(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. (5) If the client's physician has stated in writing that the client is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the client with self-administration, provided all of the following requirements are met:

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 Resident #1 and Resident #2 have been prescribed PRN medications but there is no PRN Authorization letter completed by the prescribing physician to indicate if the residents are or are not able to make their own decision to request the medication. which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/04/2026
Plan of Correction
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The Licensee will contact the prescribking physician to obtaincompleted PRN Authorization letters to confirm if the residents can determine their own need for their PRN medications and maintain in their file by 2/4/26
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Kristin Heffernan
NAME OF LICENSING PROGRAM MANAGER:
Christine Yee
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 01/28/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/28/2026


LIC809 (FAS) - (06/04)
Page: 5 of 8
Document Has Been Signed on 01/28/2026 09:05 PM - It Cannot Be Edited


Created By: Christine Yee On 01/28/2026 at 08:00 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: EMPOWER RESIDENTIAL WELLNESS CENTER LLC
FACILITY NUMBER: 195850376

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/28/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
81076(d)
81076 Food Service
(d) The licensee shall meet the following storage requirements:
(1) Supplies of staple nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days shall be maintained on the premises.


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 there was insufficient non-perishable foods observed in the cupboards for a minimum of 7 days, maintained on the premises which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/29/2026
Plan of Correction
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The Licensee will purchase additional non-perishable foods such as cereals, proteins/meats, pastas, sauces to supplement the current supply to last a minimum of 7 days and maintain on the premises.
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.
Kristin Heffernan
NAME OF LICENSING PROGRAM MANAGER:
Christine Yee
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 01/28/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/28/2026


LIC809 (FAS) - (06/04)
Page: 7 of 8
Document Has Been Signed on 01/28/2026 09:05 PM - It Cannot Be Edited


Created By: Christine Yee On 01/28/2026 at 08:11 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: EMPOWER RESIDENTIAL WELLNESS CENTER LLC
FACILITY NUMBER: 195850376

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/28/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
81025(b)
81025 Bonding
b) All licensees, other than governmental entities, who are entrusted to care for and control clients' cash resources shall file or have on file with the licensing agency, a bond issued by a surety company to the State of California as principal.

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 it was observed that the facility stores the residents' cash and dispenses as requested. Reconciliation of the cash is also done together which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/04/2026
Plan of Correction
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The Licensee will review the amount of cash being handled by the facility and purchase a Surety Bond in the appropriate amount to cover any loses. Bond required: Amount safeguarded per month and bond amount - $750 or less - $1,000, $751 to $1,500 - $2,000, $1,501 to $2,500 - $3,000, Every further increment of $1,000 or fraction thereof shall require an additional $1,000 on the bond. Provide evidence of a Surety bond by 2/4/26
Type B
Section Cited
CCR
81072(a)(7)
81072 Personal Rights
(a) Each client shall have personal rights which include, but are not limited to, the following: (7) Not to be locked in any room, building, or facility premises by day or night. (A) The licensee shall not be prohibited by this provision from locking exterior doors and windows or from establishing house rules for the protection of clients provided the clients are able to exit the facility.


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 the gate located along the side of the home, closes to the front of the home, was padlocked, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/04/2026
Plan of Correction
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The Licensee will remove remove the padlock on the side gate so that the residents may exit from the facility. Provide evidence that the padlock on the gate has been removed and that the residents may exit from the gates by 2/4/2
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Kristin Heffernan
NAME OF LICENSING PROGRAM MANAGER:
Christine Yee
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 01/28/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/28/2026


LIC809 (FAS) - (06/04)
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