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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195850608
Report Date: 06/29/2026
Date Signed: 06/29/2026 05:29:17 PM

Document Has Been Signed on 06/29/2026 05:29 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:EBELL SENIOR LIVINGFACILITY NUMBER:
195850608
ADMINISTRATOR/
DIRECTOR:		TADEVOSYAN, LUSINEFACILITY TYPE:
740
ADDRESS:13133 EBELL STREETTELEPHONE:
(818) 915-4367
CITY:NORTH HOLLYWOODSTATE: CAZIP CODE:
91605
CAPACITY: 6CENSUS: 2DATE:
06/29/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:29 AM
MET WITH:Lusine TadevosyanTIME VISIT/
INSPECTION COMPLETED:
05:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Trevor Byrne arrived at the facility unannounced to conduct the required annual visit at 10:29 AM. LPA met with facility staff who contacted facility Administrator Lusine Tadevosyan via telephone call. The facility Administrator arrived to the facility at approximately 11:15 AM. Entrance interview conducted and the reason for the visit was explained.

Beginning at 10:32 AM, the LPA, along with facility staff 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 included the living room, dining room, and hallways. LPA observed the living room to be clean and properly furnished at the time of the visit. The living room contained a couch, a television, activities for resident use, and an appropriately secured fireplace. LPA observed all required postings for the facility located on the entryway wall. The dining room was observed to be clean and contained adequate seating for resident use. LPA observed the dining room to contain a fire extinguisher that was fully charged and was purchased on 06/11/2026. The hallway was observed to be clear from obstructions. The hallway contained storage for linens and care supplies in addition to a closet which contained emergency water supplies, care supplies, and personal grooming supplies.

BEDROOMS: There are three (3) bedrooms in the facility. LPA and facility staff toured all three (3) bedrooms. All resident rooms were observed to be furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting. LPA observed one (1) resident bed to contain full bed rails. Bedrooms #2&3 contained direct exits to the outdoors 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: 06/29/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/29/2026
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: EBELL SENIOR LIVING
FACILITY NUMBER: 195850608
VISIT DATE: 06/29/2026
NARRATIVE
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INTERVIEWS: LPA interviewed one (1) resident. The resident interviewed stated that the staff treat them well and are attentive to their needs. LPA interviewed one (1) staff member. The staff member interviewed was knowledgeable on their roles and responsibilities, the resident’s rights, the forms of abuse, and the appropriate reporting procedures for suspected abuse.

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

Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited and civil penalty was assessed (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: 06/29/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/29/2026
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: EBELL SENIOR LIVING
FACILITY NUMBER: 195850608
VISIT DATE: 06/29/2026
NARRATIVE
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RECORD REVIEW: Record review began at 11:27 AM. Staff and resident records were reviewed for documents including, but not limited to: health screening, TB test, staff training records, fingerprint clearance, resident physician's report, needs and service appraisal, consent forms, and personal rights. Four (4) staff files were reviewed. All staff files contained all required documentation and signatures. Two (2) resident files were reviewed. LPA observed Resident #1 (R1)'s physician report which indicated that R1 had an ambulatory status of "Bedridden". LPA observed the facility's fire clearance to allow one (1) bedridden resident in room #3 of the facility. LPA observed that R1 resided in room #2 of the facility. LPA notified the Administrator that R1 being bedridden and residing in the wrong room constitutes a violation of the facility’s fire clearance. LPA informed the Administrator that this is a zero-tolerance violation and an immediate civil penalty in the amount of $500 will be assessed on today’s date (06/29/2026).

MEDICATION REVIEW: Medication review began at 01:41 PM. Medications for two (2) of two (2) residents were observed. All medications were stored properly. Two (2) medications were observed to have inaccurate pill counts and one (1) medication was observed to have half of a pill left imbedded in the bubble pack. LPA asked the Administrator why the pill count was off and why half of the pill was left inside the packaging. The Administrator stated that they had written the incorrect expiration date for the medication and ceased administration without a doctor’s order and that the pill must have broken in half when popped from the pack.

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 06/11/2026. The facility’s emergency disaster plan contained inaccurate information pertaining to the emergency supplies the facility had on hand. LPA informed the Administrator that they had recently signed off that the plan was reviewed but due to the inaccurate emergency supplies the plan could need to be updated. The Administrator retrieved a previous emergency disaster plan, signed the previous plan as being reviewed on 06/29/2026, and tore the more recent plan in half before LPA could make a copy of the plan. Both the infection control plan and the emergency disaster plan are reviewed/updated annually by the facility’s Administrator.

CONTINUED ON LIC 809C.

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

DATE: 06/29/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/29/2026
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: EBELL SENIOR LIVING
FACILITY NUMBER: 195850608
VISIT DATE: 06/29/2026
NARRATIVE
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BATHROOMS: There are three (3) bathrooms at the facility. Two (2) bathrooms are designated as shared resident bathrooms and one (1) is designated as a staff bathroom. All bathrooms were observed to be clean and in good repair and all were equipped with nonskid surfaces. Grab bars were observed in all showers, one (1) resident toilet was observed to be missing grab bars. All grab bars observed were properly secured. The water temperature was measured to be between 111.9 and 115.5 degrees Fahrenheit, which is within the range required by regulation. LPA observed an unsecured bottle which was unlabeled and contained a clear liquid on the floor of a resident bathroom. LPA observed this bottle to contain bleach. LPA notified facility staff who immediately secured the item. LPA observed a bathroom that was attached to bedroom #2. Facility staff informed LPA that this bathroom was being utilized as a staff bathroom only. LPA observed this bathroom’s door to contain a sign which indicated that the bathroom was a staff bathroom only. LPA notified facility staff and Administrator that no bedroom of a resident shall be used as a passageway to another room, bath or toilet.

KITCHEN/LAUNDRY: 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 observed a secured lock box which contained knives and other sharp objects. LPA observed an unsecured bottle of spray cleaner located in a cabinet under the kitchen sink. LPA notified staff who immediately secured the item. LPA observed the laundry to be located adjacent to the kitchen. LPA observed a secured cabinet in the laundry which contained detergents and extra cleaning supplies.

OUTDOOR SPACE: The facility had one (1) emergency exit gate located in the front yard. All railings located at the facility were secured properly. LPA observed clear passageways for emergency exit use. The facility had adequate shaded seating outdoors for resident use. LPA observed the backyard to contain two (2) storage sheds which contained gardening supplies and additional care supplies. LPA observed an unsecured pair of gardening shears and an unsecured bottle of pesticides. LPA notified facility staff who immediately secured the items.

CONTINUED ON LIC 809C.

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

DATE: 06/29/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/29/2026
LIC809 (FAS) - (06/04)
Page: 4 of 13
Document Has Been Signed on 06/29/2026 05:29 PM - It Cannot Be Edited


Created By: Trevor Byrne On 06/29/2026 at 04:13 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: EBELL SENIOR LIVING
FACILITY NUMBER: 195850608

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/29/2026

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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2
3
4
Based on observation, interview, and record review, the licensee did not comply with the section cited above as a bedridden resident resided in a non-bedridden approved room which poses an immediate safety risk to persons in care.
POC Due Date: 06/30/2026
Plan of Correction
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Administrator agreed to move the identified resident into the bedridden approved room and to send proof of the completed move to CCLD no later than POC due date.
Type A
Section Cited
CCR
87309(a)
Storage Space and Access
(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage.

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 cleaning chemicals, pesticides, and gardening shears were left outside of locked storage unsupervised which poses an immediate health and safety risk to persons in care.
POC Due Date: 06/30/2026
Plan of Correction
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Administrator agreed to conduct a training with all facility staff on the importance of securing dangerous items. Administrator agreed to send proof of the completed training to CCLD no later than POC due date.
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: 06/29/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/29/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/29/2026 05:29 PM - It Cannot Be Edited


Created By: Trevor Byrne On 06/29/2026 at 04:13 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: EBELL SENIOR LIVING
FACILITY NUMBER: 195850608

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/29/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(e)(4)
Maintenance and Operation
(4) Grab bars shall be maintained for each toilet, bathtub and shower used by residents.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
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Based on observation, the licensee did not comply with the section cited above as one resident toilet was observed to be missing appropriate grab bars which poses a potential safety risk to persons in care.
POC Due Date: 07/13/2026
Plan of Correction
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Administrator agreed to install appropriate grab bars for the identified resident toilet and to send proof of the installed bars to CCLD no later than POC due date.
Type B
Section Cited
CCR
87309(a)(2)
Storage Space and Access
(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage. (2) Any items in subsection (a)(1) that are transferred from their original container to another container shall have a legible label that indicates:

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 bleach was stored in an unmarked clear spray bottle left unattended in a resident bathroom which poses a potential health and safety risk to persons in care.
POC Due Date: 07/13/2026
Plan of Correction
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Administrator agreed to appropriately label any and all chemicals stored in the facility that are not in their original container and to send proof of the appropriately labeled containers to CCLD no later than POC due date.
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: 06/29/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/29/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/29/2026 05:29 PM - It Cannot Be Edited


Created By: Trevor Byrne On 06/29/2026 at 04:13 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: EBELL SENIOR LIVING
FACILITY NUMBER: 195850608

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/29/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(a)(4)
Incidental Medical and Dental Care Services
(4) The licensee shall assist residents with self-administered medications as needed.

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 two medications contained errors in the pill count and half of a pill was left imbedded in the packaging and was not administered to the resident which poses a potential health risk to persons in care.
POC Due Date: 07/13/2026
Plan of Correction
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Administrator agreed to write a statement of understanding confirming that they are aware of the importance of accurately logging and administering medications and confirming that they will adhere to all requirements when logging/administering medications in the future. Administrator agreed to submit the statement to CCLD no later than POC due date.
Type B
Section Cited
HSC
1569.695(a)
Other Provisions
(a)In addition to any other requirement of this chapter, a residential care facility for the elderly shall have an emergency and disaster plan that shall include, but not be limited to, all of the following:

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 the emergency disaster plan contained inaccurate information pertaining to the emergencty supplies the faciltiy had on hand which poses a potential safety risk to persons in care.
POC Due Date: 07/13/2026
Plan of Correction
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Administrator agreed to revise the facility's emergency disaster plan and to send the updated plan to CCLD no later than POC due date.
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: 06/29/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/29/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/29/2026 05:29 PM - It Cannot Be Edited


Created By: Trevor Byrne On 06/29/2026 at 04:13 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: EBELL SENIOR LIVING
FACILITY NUMBER: 195850608

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/29/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87608(a)(5)(B)
Postural Supports
(B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation and record review, the licensee did not comply with the section cited above as one resident who was not receiving hospice care had full bed rails installed which poses a potential personal rights risk to persons in care.
POC Due Date: 07/13/2026
Plan of Correction
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Administrator agreed to remove the rails and to send proof to CCLD no later than POC due date.
Type B
Section Cited
CCR
87307(a)(2)(C)
87307 Personal Accommodations and Services
(a) Living accommodations and grounds shall be related to the facility's function. The facility shall be large enough to provide comfortable living accommodations and privacy for the residents, staff, and others who may reside in the facility. The following provisions shall apply:
(2) Resident bedrooms shall be provided which meet, at a minimum, the following requirements:
(C) No bedroom of a resident shall be used as a passageway to another room, bath or toilet.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and interview, the licensee did not comply with the section cited above as bedroom #2 was being utilized as a passageway to a staff only bathroom which poses a potential personal rights risk to persons in care.
POC Due Date: 07/13/2026
Plan of Correction
1
2
3
4
Administrator agreed to utilize the attached bathroom to bedroom #2 as a private resident bathroom. Administrator agreed to remove all stored items and signage indicating that this is a staff bathroom and to send proof of the removed items to CCLD no later than POC due date.
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: 06/29/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/29/2026


LIC809 (FAS) - (06/04)
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