195850486-5-29-2026-29-AS-QHUH-DUHQEX-20260528120704

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 195850486
Report Date: 05/28/2026
Date Signed: 05/29/2026 09:44:14 AM

Document Has Been Signed on 05/29/2026 09:44 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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	WALNUT GARDEN IV		FACILITY NUMBER:	195850486
ADMINISTRATOR/ DIRECTOR:	ILLOUZ, IZHAK		FACILITY TYPE:	740
ADDRESS:	5128 CEDROS AVE		TELEPHONE:	(818) 855-1459
CITY:	SHERMAN OAKS	STATE: CA	ZIP CODE:	91403
CAPACITY: 6		CENSUS: 6	DATE:	05/28/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	10:28 AM
MET WITH:	Ayalla Levy - Administrator Izhak Illouiz - Licensee		TIME VISIT/ INSPECTION COMPLETED:	10:29 AM

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 Analyst (LPA) Quoc Huynh arrived at the facility unannounced to conduct a required annual visit at 9:55AM. The LPA met with the Administrator Ayalla Levy and Licensee Izhak Illouz arrived shortly thereafter. Entrance interview conducted. Beginning at 9:58AM, the LPA and Administrator toured the physical plant areas inside and outside to ensure there are no health and safety hazards, and facility is in compliance with Title 22 Regulations. The following was observed: BEDROOMS/RESTROOMS: There are seven (7) total bedrooms; six (6) private resident bedrooms and one (1) locked staff bedroom. Bedrooms were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. Extra linens are stored in the hallway cabinets. There are seven (7) total restrooms in the facility: five (5) attached private resident restrooms, one (1) designated staff and visitor restroom, and one (1) shared resident restroom. Restrooms were clean and sanitary and in operating condition with grab bars and non-slip surfaces. All restrooms were sufficiently stocked with soap, paper products, and displayed hand washing signs. Hot water was tested and measured between 112.6 degrees F and 115.3 degrees F. Report Continued on LIC 809-C NOTE: Report amended to clarify LPA's visit time of 09:55AM to 12:15PM. Report emailed to Licensee for signature.

NAME OF LICENSING PROGRAM MANAGER: Kristin Heffernan
NAME OF LICENSING PROGRAM ANALYST: Quoc Huynh
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/28/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2026

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: WALNUT GARDEN IV	FACILITY NUMBER: 195850486
	VISIT DATE: 05/28/2026

NARRATIVE

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COMMON AREAS: At the time of the visit, living room and dining room furniture was observed to be in good condition with activity storage. A screened and inoperable fireplace was observed. Required postings were located in the living room near a secured closet that contained general storage. A locked laundry room was located in the hallway and contained an operable washer/dryer, laundry supplies, and household cleaning supplies. The facility maintained a comfortable temperature throughout the visit.

KITCHEN: Knives are stored inaccessible in a locked drawer and cleaning supplies inaccessible under the sink. Kitchen appliances were clean and in operable condition. The facility had a supply of perishable and non-perishable food, as well as emergency food. Food in the refrigerator and freezer were observed to be properly stored.

OUTDOOR AREA: The surrounding grounds had multiple shaded patio areas equipped with furniture in good condition for resident and visitor use. There is one driveway gate used for emergency exits with two pathways on both sides of the house that lead to the front yard/driveway. No bodies of water noted, and exits are free of obstructions. The LPA observed three (3) sheds in the backyard that stored extra freezer foods, emergency water, and general storage. The sheds remain locked and inaccessible to residents in care.

RECORDS: Record review began at 10:33AM. Resident records were reviewed for, but not limited to care plans, physician's report, admissions agreement, and consent forms. All records were in order. Personnel records were reviewed for, but not limited to health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All records were in order.

Report Continued on LIC 809-C

NAME OF LICENSING PROGRAM MANAGER: Kristin Heffernan
NAME OF LICENSING PROGRAM ANALYST: Quoc Huynh
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/28/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2026

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: WALNUT GARDEN IV	FACILITY NUMBER: 195850486
	VISIT DATE: 05/28/2026

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INFECTION CONTROL/EMERGENCY DISASTER PLAN: During today's visit, LPA reviewed the facility's infection control plan and emergency disaster plan. Both documents were observed to be complete and reviewed annually as required. Fire extinguishers were observed throughout the facility and were last serviced on 01/06/2026. Emergency disaster drills are conducted quarterly, with the last documented drill on 02/05/2026. Smoke and carbon monoxide detectors were tested at 11:16AM and were operational.

MEDICATIONS: Medication review began at 11:19AM. Medications are centrally stored and kept inaccessible in the hallway closet. Medications were observed for two (2) residents. Medications were labeled and checked for expiration dates. Medications were properly documented on the centrally stored medications and destruction record. No errors observed during the medication review.

No deficiency cited. Exit interview conducted. A copy of the report was reviewed and provided.

NAME OF LICENSING PROGRAM MANAGER: Kristin Heffernan
NAME OF LICENSING PROGRAM ANALYST: Quoc Huynh
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/28/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2026

LIC809 (FAS) - (06/04)

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