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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195850495
Report Date: 11/24/2025
Date Signed: 11/24/2025 07:29:15 PM

Document Has Been Signed on 11/24/2025 07:29 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:DOLLY HOUSEFACILITY NUMBER:
195850495
ADMINISTRATOR/
DIRECTOR:		PIPPARD, JENNIFERFACILITY TYPE:
735
ADDRESS:6500 WHITSETT AVENUETELEPHONE:
(818) 762-4365
CITY:NORTH HOLLYWOODSTATE: CAZIP CODE:
91606
CAPACITY: 6CENSUS: 6DATE:
11/24/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:24 AM
MET WITH:Jessica Mercado, StaffTIME VISIT/
INSPECTION COMPLETED:
07:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Christine Yee conducted an unannounced required Annual Inspection and utilized the CARE Inspection Tool to conduct the visit. LPA Yee met with Jessica Mercado, Staff at the Activities for Retarded Children and Adults, the home's sister facility. Jennifer Pippard, Administrator and Corrine Botte, Operations Manager were not available to conduct the site visit due to a family emergency and childcare issues. Selina West, Lead Staff assisted in the visit. The reason for today's visit was explained

The facility is single storey family home consisting of a living room, dining room, a kitchen, laundry room, 6 resident bedrooms, an office/medication room, 3 common bathrooms and a full private bathroom in the conference/storage room and a 1/2 bathroom for staff use. The facility is fire cleared for 6 NON-AMBULATORY clients.

On today visit, LPA Yee conducted a tour of the physical plant to ensure that the home still met Title 22 requirements. On today's visit, LPA Yee observed that the facility did not create new files for staff or clients once the application process was completed and the facility licensed. The staff and client files are from the previous operations including unlicensed care.

The Physical Plant and Environmental Safety domain was the only domain reviewed on today's visit. The following was observed on today's visit:


continued on LIC809-C
NAME OF LICENSING PROGRAM MANAGER: Kristin Heffernan
NAME OF LICENSING PROGRAM ANALYST: Christine Yee
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 11/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/24/2025
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: DOLLY HOUSE
FACILITY NUMBER: 195850495
VISIT DATE: 11/24/2025
NARRATIVE
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  • the living room is furnished with a sofa, love seat, 2 arm chairs and a stand with a television
  • the dining room is furnished with a long dining room table and 6 chairs.
  • the kitchen is equipped with a stove, 2 refrigerators, 2 dishwasher and a microwave. Plates, bowls, drinking cups, forks and spoons for 6 residents were observed. Pots and pans for cooking. Sufficient perishable foods for a minimum 2 days and insufficient non-perishables for a minimum of 7 days were observed. Knives are stored in a locked drawer.
  • the laundry room was observed with a washer and dryer and were operational. Laundry detergent are stored in a locked cupboard.
  • Bedrooms #1, #2, #4, #5 all have a twin bed, bedrooms #3 and #6 have full sized bed. All 6 bedrooms also contained a night stand, a chair, a dresser, a lamp and a built in closet. The covering for the chairs located in bedroom #1, #2, #4 were observed to be worn out and needs to be re-upholstered.
  • The facility also has a large conference/storage room with a full bathroom located inside.
  • All the required bed linens were observed on all the beds except that there were no regular sized warm blankets on all the beds and no comforter in bedroom #3.
  • The slates on the bedroom blinds in bedroom #6 are broken
  • The fire rated door between the living room and resident rooms did not close tightly when the smoke detectors were tested and needs to be adjusted to allow the door to close tightly during a fire.
  • The home has 3 full common bathrooms, 1 private bathroom located in the large conference/storage room and a 1/2 bathroom for staff use. The bathrooms are equipped with a walk in shower, a toilet and a single sink. Grab bars and slip resistant mats were observed. Shower chairs were observed in the 3 common bathrooms.
  • The water tested in the back bathroom read 106.7 degrees, the middle bathroom read 118.6 degrees, the front bathroom read 119.7 degrees, the kitchen read 119.7 degrees and the staff bathroom read 119 degrees Fahrenheit.
  • Centrally stored medications and the previous client files are stored in the office
  • The facility has 2 fire extinguishers. One is located by the back door and one by the side door leading on to Hamlin Street. They were last serviced on 9/25/25.



continued on LIC809-C
NAME OF LICENSING PROGRAM MANAGER: Kristin Heffernan
NAME OF LICENSING PROGRAM ANALYST: Christine Yee
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 11/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/24/2025
LIC809 (FAS) - (06/04)
Page: 3 of 9
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: DOLLY HOUSE
FACILITY NUMBER: 195850495
VISIT DATE: 11/24/2025
NARRATIVE
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  • the hall way to the bathrooms are not equipped with night lights because the hall way lights are left on all night.
  • The laundry room located by kitchen was observed with a washer and dryer.
  • Table with chairs and a umbrella was observed in the middle courtyard.
  • The backyard is equipped with a ramp. Trash cans were observed on the street for pickup on Tuesday.
  • the front yard was observed to be clean.
  • The staff conducting the visit was not associated to the facility.



Deficiencies cited under California Code of Regulations, Title 22, Division 6, Chapter 1. Any deficiencies not cited on today's visit will be cited on a return visit. CIVIL PENALTIES WERE ASSESSED.


Exit interview was conducted, APPEALS RIGHTS WERE DISCUSSED and a copy was provided.
NAME OF LICENSING PROGRAM MANAGER: Kristin Heffernan
NAME OF LICENSING PROGRAM ANALYST: Christine Yee
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 11/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/24/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/24/2025 07:29 PM - It Cannot Be Edited


Created By: Christine Yee On 11/24/2025 at 04:59 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: DOLLY HOUSE
FACILITY NUMBER: 195850495

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/24/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85088(c)(4)
Fixtures, Furniture, Equipment, and Supplies
(c) 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 wash cloths.

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 no regular sized blankets were observed on any of the clients beds and a comforter was not observed on the bed in bedroom #3, also there weren't sufficient flat sheets observed in the linen closet which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/02/2025
Plan of Correction
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The Licensee will provide or purchase blankets, comforters and flat sheets in quantities that allow for weekly changing or as needed. The licensee will provide evidence that they have purchased blankets, comforters and flat sheets in quantities that allow for weekly changing or as needed by 12/2/25
Type B
Section Cited
CCR
80087(a)
80087 Buildings and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.


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 blinds on the back glass door in bedroom #6 are broken which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/02/2025
Plan of Correction
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The Licensee will repair or replace the blinds on the back glass door in room #6 and provide evidence that the blinds have been replaced by 12/2/15
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: 11/24/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/24/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/24/2025 07:29 PM - It Cannot Be Edited


Created By: Christine Yee On 11/24/2025 at 05:38 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: DOLLY HOUSE
FACILITY NUMBER: 195850495

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/24/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80019(e)(3)
80019 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 80019(f) or


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above as the staff assisting with today's visit, Jessica Mercado, Staff at the sister facility across the street is not associated to the facility which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/25/2025
Plan of Correction
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The Licensee will take steps to ensure that all individuals subject to a criminial record review pursuant to Health and safety code Section 1522 shall prior to working, residing or volunteering in a licensed care facility request a transfer of a criminal record as specified in Section 80019(f)
Type A
Section Cited
CCR
85076(d)(1)
85076 Food Service
(d) The licensee shall meet the following food supply and 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 as the food observed consisted mostly of ingredients and not suffiicent in quantities to make balanced meals for 7 days which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/25/2025
Plan of Correction
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The Licensee will purchase additional non-perishable foods such as chicken, fish, beef, pre-made chili, soups to allow for the preparation of balanced meals for 7 days. Licensee will provide evidence that sufficient non-perishable foods are purchased and maintained on the premises by 11/25/25
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: 11/24/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/24/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/24/2025 07:29 PM - It Cannot Be Edited


Created By: Christine Yee On 11/24/2025 at 06:08 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: DOLLY HOUSE
FACILITY NUMBER: 195850495

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/24/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
85051(a)(3)
85051 Serious Deficiencies (a)(3) The following are examples of regulations that, if not complied with, nearly always result in a serious deficiency. Section 80020 relating to fire clearance.

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 when the smoke detectors were tested, the fire rated door did not automatically close until the 2 test and when it did close, it did not close the door tightly to secure the resident hallway from the liiving room which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/25/2025
Plan of Correction
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The Licensee will have the door serviced to ensure that the fire rated door seals the door way completely to prevent the spread of flames to allow the clients to exit safely. Evidence that the deficiency corrected by 11/25/25.
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: 11/24/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/24/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/24/2025 07:29 PM - It Cannot Be Edited


Created By: Christine Yee On 11/24/2025 at 06:28 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: DOLLY HOUSE
FACILITY NUMBER: 195850495

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/24/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80066(a)
80066 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 observation,interview and review, the licensee did not comply with the section cited above in all counts as the facility has not created any new files with updated records and is still using previous files which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/02/2025
Plan of Correction
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The Licensee will read Title 22, Section 80066 and Section 85066 and submit a written statement that the section was read and understood. Files for Staff and volunteers will be created and Licensee will notify LPA Yee when the files have been completed by 12/2/25
Type B
Section Cited
CCR
80070(a)
80070 Client Records
a) The licensee shall ensure that a separate, complete, and current record is maintained in the facility for each client.


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above as Client files were not created upon licensure. Facility is still using the previous client files which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/02/2025
Plan of Correction
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The Licensee will read Title 22, Section 80070 and 85070 and submit a written statement that the sections have been read and understood. Licensee will also create files for all clients containing the required documents and will let LPA Yee know when the files have been completed by 12/2/25
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: 11/24/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/24/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/24/2025 07:29 PM - It Cannot Be Edited


Created By: Christine Yee On 11/24/2025 at 07:14 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: DOLLY HOUSE
FACILITY NUMBER: 195850495

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/24/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
80087 Buildings and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, 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 as the chairs in bedroom #1, #2 and #4 were observed worn out which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/02/2025
Plan of Correction
1
2
3
4
Licensee will re-upholster or replace the chairs in bedroom #1, #2 and #4. Evidence that the chairs have been re-upholstered or replaced by 12/2/25.
Section Cited
Deficient Practice Statement
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2
3
4
POC Due Date:
Plan of Correction
1
2
3
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.
Kristin Heffernan
NAME OF LICENSING PROGRAM MANAGER:
Christine Yee
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 11/24/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/24/2025


LIC809 (FAS) - (06/04)
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