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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195850520
Report Date: 02/10/2026
Date Signed: 02/10/2026 04:30:36 PM

Document Has Been Signed on 02/10/2026 04:30 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:FINE GOLD MANORFACILITY NUMBER:
195850520
ADMINISTRATOR/
DIRECTOR:		CRISTINA GOMEZFACILITY TYPE:
740
ADDRESS:10537 MAGNOLIA BLVD.TELEPHONE:
(818) 761-5777
CITY:NORTH HOLLYWOODSTATE: CAZIP CODE:
91601
CAPACITY: 100CENSUS: 60DATE:
02/10/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:02 AM
MET WITH:Christina GomezTIME VISIT/
INSPECTION COMPLETED:
04:30 PM
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Licensing Program Analyst (LPA) Trevor Byrne arrived at the facility unannounced to conduct the required annual visit at 11:02 AM. LPA met with facility staff who contacted the facility Administrator Christina Gomez. The Administrator arrived to the facility at 11:15 AM. Entrance interview was conducted and the reason for the visit was explained.

Beginning at approximately 11:20 AM the LPA, along with the facility Administrator toured the physical plant areas inside and outside to ensure there are no health and safety hazards and that facility is in compliance with Title 22 Regulations. The following was observed:

COMMON AREAS: This includes the TV room, Activity room, hallway, and dining area. LPA observed the TV room and activity room to be clean and properly furnished at the time of the visit. These rooms contained a television, adequate seating, and activities for resident use. The hallway was observed to be clean and free from any obstructions. The hallway contained locked storage closets which contained storage for linens, cleaning chemicals, decorations, maintenance supplies, and care supplies. The dining area was observed to be equipped with adequate seating for resident use. The entryway and lobby contained all required postings. LPA observed a hallway closet to contain adequate emergency food and water supplies for the facility. The facility’s fire detection system were tested by Advance Building Protection and was certified through 03/31/2026. LPA observed the hallway to contain wall mounted fire extinguishers which were fully charged and were last serviced on 11/22/2024 and 01/18/2023 which is outside of the range required by regulation. LPA informed the Administrator who agreed to have a technician come out to service all fire extinguishers in the facility. All exits in the facility were observed to be free from any obstructions. LPA observed cameras located throughout the common areas of the facility. Continued on LIC 809C.
NAME OF LICENSING PROGRAM MANAGER: Kasandra Lopez
NAME OF LICENSING PROGRAM ANALYST: Trevor Byrne
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 02/10/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/10/2026
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.

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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: FINE GOLD MANOR
FACILITY NUMBER: 195850520
VISIT DATE: 02/10/2026
NARRATIVE
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BEDROOMS: There are sixty four (64) bedrooms in the facility; five (5) are dual occupancy resident rooms, fifty nine (59) are single occupancy resident rooms. LPA and the Administrator toured ten (10) bedrooms. All ten (10) resident rooms observed were furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting. LPA unannounced tested the signal alert system in two (2) resident bedrooms at 11:54 AM and at 12:23 PM and received immediate responses over the PA system from facility staff.

KITCHEN: The LPA observed the kitchen area to be clean. Kitchen appliances appeared to be in operable condition. The facility had a sufficient supply of two (2) days perishable and seven (7) days non-perishable food. LPA tested the water temperature in the kitchen and observed the temperature to be 109.2 degrees Fahrenheit, which is in compliance with regulation. LPA observed the kitchen to contain a wall mounted fire extinguisher which was fully charged and last serviced on 11/22/2024 which is outside of the range required by regulation.

BATHROOMS: There are three (3) common resident bathrooms at the facility and each bedroom has an attached private resident bathroom. All resident bathrooms observed were clean and were equipped with nonskid surfaces. Grab bars were observed in all inspected showers and near all inspected toilets, all were properly secured. The water temperature was measured to be between 107.4 and 111.9 degrees Fahrenheit, which is in compliance with regulation.

GARAGE: LPA observed the garage to contain a locked chemical storage, a locked maintenance room, various machinery rooms, and a theater which was under construction at the time of this report. LPA observed a working automatic gate at the access to the garage. LPA observed clear passageways for emergency exit use.

OUTDOOR SPACE: The facility had adequate shaded seating outdoors for resident use. LPA observed all emergency exits to be clear from obstructions. LPA observed cameras located throughout the outdoor areas of the facility.

Continued on LIC 809C.
NAME OF LICENSING PROGRAM MANAGER: Kasandra Lopez
NAME OF LICENSING PROGRAM ANALYST: Trevor Byrne
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 02/10/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2026
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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: FINE GOLD MANOR
FACILITY NUMBER: 195850520
VISIT DATE: 02/10/2026
NARRATIVE
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RECORD REVIEW: Record review began at 12:36 PM. Resident records were reviewed for documents including, but not limited to: health screening, TB test, physician's report, needs and service appraisal, consent forms, and personal rights. Six (6) resident files were reviewed. LPA observed Resident #1 (R1)’s bedroom to contain a wheelchair. Upon reviewing R1’s file LPA observed their physician report from 2024 to list R1 as “Ambulatory”. LPA observed a request form where R1 indicated that they required a wheelchair and walker. LPA informed the Administrator who stated that R1 utilizes the wheelchair on longer outings. LPA informed the Administrator that R1 was listed as “Ambulatory” but utilization of a wheelchair/walker constitutes a change in condition of R1 and a reappraisal of R1 will need to be conducted by a medical provider to determine if R1’s ambulatory status has changed since their last physician’s report. The Administrator expressed understanding and agreed to complete an updated assessment of R1 with a medical professional.

INFECTION CONTROL/EMERGENCY DISASTER PLANNING: During today’s visit, the LPA reviewed the
facility's infection control practices and the facility's emergency disaster plan. The facility’s policies and procedures as they pertain to infection control are adequate. Emergency disaster drills are conducted quarterly; the facility’s last emergency disaster drill was conducted on 01/23/2026. The facility’s emergency disaster plan is up to date and is adequate. Both the infection control plan and the emergency disaster plan are reviewed/updated annually by the facility’s Administrator.

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

Due to time constraints LPA will return at a later date to conduct four (4) additional resident file reviews, staff file review, medication review, and interviews. Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D): Exit interview conducted and copy of the report was issued and appeal rights provided.

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

DATE: 02/10/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2026
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/10/2026 04:30 PM - It Cannot Be Edited


Created By: Trevor Byrne On 02/10/2026 at 03:18 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: FINE GOLD MANOR
FACILITY NUMBER: 195850520

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/10/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87202(a)
Fire Clearance
(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal:

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 facility fire extinguishers were last serviced on 11/22/2024 and one on 01/18/2023 which poses an immediate safety risk to persons in care.
POC Due Date: 02/11/2026
Plan of Correction
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Administrator agreed to have all fire extinguishers serviced by a licensed professional and to submit proof of all serviced fire extinguishers to CCLD no later than POC due date.
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.
Kasandra Lopez
NAME OF LICENSING PROGRAM MANAGER:
Trevor Byrne
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 02/10/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/10/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/10/2026 04:30 PM - It Cannot Be Edited


Created By: Trevor Byrne On 02/10/2026 at 03:21 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: FINE GOLD MANOR
FACILITY NUMBER: 195850520

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/10/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87463(a)
87463 Reappraisals
(a) The pre-admission appraisal, as specified in Section 87457, Pre-Admission Appraisal, shall be updated in writing as frequently as necessary or once every 12 months, whichever occurs first, to note significant changes in condition, as defined in Section 87101, Definitions, and to keep the appraisal accurate. For the purposes of this section, the updated pre-admission appraisal shall be referred to as the reappraisal.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above as one resident was observed to have a wheelchair in their room and a signed request for a wheelchair/walker but was listed to be Ambulatory on their 2024 physician's report with no re-appraisal which poses a potential health and safety risk to persons in care.
POC Due Date: 02/24/2026
Plan of Correction
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Administrator agreed to have a medical professional reassess R1 to determine if R1’s ambulatory status has changed since their last physician’s report. Administrator agreed to submit proof of the reappraisal to CCLD no later than POC due date.
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.
Kasandra Lopez
NAME OF LICENSING PROGRAM MANAGER:
Trevor Byrne
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 02/10/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/10/2026


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