<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197600865
Report Date: 07/01/2025
Date Signed: 07/01/2025 04:31:00 PM

Document Has Been Signed on 07/01/2025 04:31 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 S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:VAGTHOL'S RESIDENTIAL CARE CENTERFACILITY NUMBER:
197600865
ADMINISTRATOR/
DIRECTOR:		CHAMU-NESTOR, FRANCISCAFACILITY TYPE:
735
ADDRESS:418 N. MARIPOSATELEPHONE:
(818) 562-1447
CITY:BURBANKSTATE: CAZIP CODE:
91506
CAPACITY: 6CENSUS: 6DATE:
07/01/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Rodel Serrano-AdministratorTIME VISIT/
INSPECTION COMPLETED:
04:30 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) Nadia Shahbazian conducted an unannounced Required-1 year visit. LPA was met by Roy Nortiga/Staffing Coordinator and explained the purpose of the visit. Administrator, Rodel Serrano was called on the phone and arrived at 10:30am to assist LPA with the inspection. The facility is an Adult Residential Facility (ARF) licensed to care for six (6) Developmentally Disabled Non Ambulatory Adults, ages 18 through 59. Facility was granted exceptions by Community Care Licensing (CCL) for five (5) clients over the age of 59. All clients residing at this facility receive case management services provided by Frank D. Lanterman Regional Center.

LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today. At 10:15 LPA conducted the facility tour and observed the following:

Required postings were observed in the office and dining room. The front entry is the main exit but there are additional exists in the kitchen and each bedroom, leading to the backyard. There are four fire extinguishers, one in the kitchen, one in the garage, one in hallway and one in storage closet. All fire extinguishers are fully charged and were serviced on 09/05/2024. Facility has fire sprinklers installed in each room. Smoke and carbon monoxide detectors are not interconnected. At 11:10am smoke and carbon monoxide detectors were tested and observed to be operable. Facility conducts monthly fire and safety drills, the last fire drill was conducted on 06/16/25.

Operational Requirements: Facility has a transportation van with valid car insurance through 09/15/2025. Surety Bond in the amount of $10,000 is in effect and will expire on 05/20/2026. Facility Certificate of Liability Insurance has an expiration date of 07/13/2025.


Continued on 809-C
NAME OF LICENSING PROGRAM MANAGER: Eva Miller
NAME OF LICENSING PROGRAM ANALYST: Nadia Shahbazian
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/01/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/01/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4
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)
Page: 2 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: VAGTHOL'S RESIDENTIAL CARE CENTER
FACILITY NUMBER: 197600865
VISIT DATE: 07/01/2025
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
26
27
28
29
30
31
32
Kitchen: The kitchen appliances consisted of a refrigerator, stove, dishwasher and microwave and the fixtures were observed to be functional. Knives, cutlery and sharp kitchen objects are stored in locked kitchen cabinet underneath the sink. The cleaning supplies were also locked in cabinet underneath the sink. LPA found a sufficient supply of perishable foods (2 days) and non-perishable food (7 days) supplies, with sufficient amount of dishes for the census of six (6). LPA observed all food in freezer and refrigerator to be labeled with dates; also the medication for one (1) client was kept in a locked box in the refrigerator.

Bathrooms: There are two (2) bathrooms designated for staff and residents’ use. All toilets and sinks are maintained in sanitary, operating condition. LPA observed proper grab bars and non-skid mats in both bathrooms. Hot water temperature was measured at 107.8 and 108 degrees Fahrenheit.

Bedrooms: There are five (5) bedrooms designated for clients' use. All of the bedrooms were properly furnished with appropriate chairs, beddings, linens with sufficient lighting. LPA observed that four (4) clients are using half-length bedrails, all of them have physician's orders for half-length bedrails.

Common Areas: Include a living room and dining room. The common areas were properly furnished with ample sitting/tables for appropriate number of clients. Television set and activity/gaming areas were observed in the dining room.

Surrounding grounds: Entry/exit gates and pathways were free of obstruction. The outdoor area was free of visible immediate hazards. No bodies of water were observed at the facility. There is ample patio space for outdoor activities. There were two shaded patio areas with furniture appropriate for outdoor use. There is a locked shed in the backyard, where facility keeps supplies such as incontinence pads. Facility has a detached garage, where additional supplies are kept. Laundry machines, detergents and toxins are maintained locked in the garage, inaccessible to clients in care.

Medications and First-Aid Kits: LPA observed all medications and two complete first-aid kits and the first aid manual, locked in a kitchen cabinet.

Continued on 809-C

NAME OF LICENSING PROGRAM MANAGER: Eva Miller
NAME OF LICENSING PROGRAM ANALYST: Nadia Shahbazian
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/01/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2025
LIC809 (FAS) - (06/04)
Page: 3 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: VAGTHOL'S RESIDENTIAL CARE CENTER
FACILITY NUMBER: 197600865
VISIT DATE: 07/01/2025
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
26
27
28
29
30
31
32
Staff Files: Staff files were reviewed to ensure all forms and training certificates are up to date.

Resident Files: A review of resident records to ensure compliance of licensing forms was conducted. Residents files included but were not limited to: Physician's Report (including TB and Ambulatory Status), Consent For Medical Treatment, Individual Program Plan (IPP), Behavioral Reports, Client Cash Resources, Special Incident Reports, Client Personal Property and Clients Personal Rights observed. Medications records for residents were also verified for accuracy of administration based on physician orders. LPA also conducted an audit of resident cash resources and compared them to receipts.

Pursuant to Title 22 Division 6 of the CA Code of Regulations, no deficiencies observed during the visit.

Exit Interview Conducted / A Copy of the Report provided to Administrator.

NAME OF LICENSING PROGRAM MANAGER: Eva Miller
NAME OF LICENSING PROGRAM ANALYST: Nadia Shahbazian
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/01/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2025
LIC809 (FAS) - (06/04)
Page: 4 of 4