197600306-3-28-2025-29-AS-CYEE-DF85WU-20250328201944

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197600306
Report Date: 03/28/2025
Date Signed: 03/28/2025 08:20:00 PM

Document Has Been Signed on 03/28/2025 08:20 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:	ACTIVITIES FOR RETARDED CHILDREN AND ADULTS		FACILITY NUMBER:	197600306
ADMINISTRATOR/ DIRECTOR:	CAROLE-ANN SCOTT		FACILITY TYPE:	775
ADDRESS:	6456 WHITSETT AVE.		TELEPHONE:	(818) 762-4365
CITY:	NORTH HOLLYWOOD	STATE: CA	ZIP CODE:	91606
CAPACITY: 36		CENSUS: 0	DATE:	03/28/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	10:10 AM
MET WITH:	Corrine Botte, Operations Manager		TIME VISIT/ INSPECTION COMPLETED:	08:25 PM

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) Christine Yee conducted an unannounced required Annual Inspection using the entire CARE Inspection Tool and was initially met by Jessica Mercado, Staff. Corrine Botte, Operations Manager was contacted and she arrived a little later to conduct the visit. Jennifer Pippard, Executive Director was working off site, but also arrived to participate in today's visit. The reason for today's visit was explained. The facility is a two storey building consisting of a large activity room(Great Room), living room, arts and crafts room, dining room, library(Tile Room), 2 bathroom, break room and kitchen on the first floor. The second floor consists of 3 offices, a computer room and 2 bathrooms. There is also a detached garage on the premises and is equipped as a gym. The facility is fire cleared for AMBULATORY clients only and is vendorized by the North Los Angeles County Regional Center. All 12 domains of the CARE inspection Tool were reviewed, 5 staff and 5 client files were reviewed and a tour of the entire facility, inside and outside, was conducted. No clients were in attendance on today's visit due to repairs being done to the electrical box. The following was observed on today's visit: the living room is furnished with sofas, end tables and a activity table with chairs. Located in the living is a fire place that needs a fire screen the dining/art room is equipped with a dining room table and chairs for activities. the kitchen has a refrigerator, a dishwasher, 2 microwaves and a stove. The kitchen is not used to

NAME OF LICENSING PROGRAM MANAGER: Kristin Heffernan
NAME OF LICENSING PROGRAM ANALYST: Christine Yee
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 03/28/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2025

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: ACTIVITIES FOR RETARDED CHILDREN AND ADULTS	FACILITY NUMBER: 197600306
	VISIT DATE: 03/28/2025

NARRATIVE

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to prepare meals. The kitchen is used occasionally for cooking activities. Located in the kitchen are 2 tables and chairs for cooking and other activities. Dish soaps and detergents are stored in a locked cabinet under the sink.
Cleaning solutions and knives are stored in the locked stairwell cupboard.
the large activity room, known as the Great Room is furnished with 36 chairs, folding tables and a large television.
the library/Tile room has a table with 4 chairs and books.
clients' belongings and coats are stored in closet by the front door.
2 bathrooms with a toilet and a sink are located by the kitchen
Located upstairs are the administrative offices and 2 full bathrooms. Medications are stored in a locked cupboard in office located by the top of the stairs.
Fire extinguishers located in the kitchen, Library/Tile room and upstairs were all serviced on 10/9/24.
The first aid kit and first aid manual were observed with the required tweezer, scissors and thermometer.
the 3 combination smoke/carbon monoxide detector located in the 3 upstairs offices and the smoke detector in the Tile room were tested and were operational. The smoke detector by the kitchen and the 2 in the living room did not work.
The front yard was observed with 8 tables, 32 chairs and 5 umbrellas for lunch and outside activities.
The backyard has a drive way, detached garage and is set up with 2 park benches
The hot water could not be tested as the facility was having the electrical box repaired. The tank less heater operates on electricity. The Executive Director will provide water temperature readings when the electrical box has been repaired.
The garage was observed with 3 stationary bikes and 4 tread mills.
Overall, the inside and outside areas were observed to be clean.

Deficiencies cited under California Code of Regulations, Title 22 Division 6, Chapter 3

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: 03/28/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 03/28/2025 08:20 PM - It Cannot Be Edited

Created By: Christine Yee On 03/28/2025 at 07:38 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: ACTIVITIES FOR RETARDED CHILDREN AND ADULTS	FACILITY NUMBER: 197600306
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/28/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

82087(a)

Buildings and Grounds

(a) The program site 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 it was observed that the smoke detector located in the hallway by the kitchen and the 2 in the living room were not working when it was tested which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/04/2025
	Plan of Correction
1 2 3 4	The Licensee will ensure that the smoke detectors and carbon monoxide detectors are inspected monthly to ensure that they are in working condition. Licensee will replace the defective smoke detectos and provide evidence that they were replaced by 4/4/25

Type B

Section Cited

CCR

82088(c)(1)

82088 Fixtures, Furniture, Equipment, and Supplies (c) Fireplaces and open-faced heaters shall be made inaccessible to clients to ensure protection of the clients' safety. 1) The use of a fireplace screen or similar barrier will meet this requirement. 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 it was observed that the fire place in the living room was not made inaccessible to the clients in care, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/04/2025
	Plan of Correction
1 2 3 4	The Licensee will purchase a fire screen and place it in front of the fireplace to make it inaccessible to the clients in care by 4/4/25. ************deficiencycorrected at the time of the visit*******************

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: 03/28/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2025

LIC809 (FAS) - (06/04)

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