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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197602348
Report Date: 09/17/2025
Date Signed: 09/17/2025 04:01:00 PM

Document Has Been Signed on 09/17/2025 04:01 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:ST. ANNE'S GOLDEN YEARS HOMEFACILITY NUMBER:
197602348
ADMINISTRATOR/
DIRECTOR:		TIOPIANCO, MARIAFACILITY TYPE:
740
ADDRESS:5153 EAGLEROCK BOULVARDTELEPHONE:
(323) 550-1170
CITY:LOS ANGELESSTATE: CAZIP CODE:
90041
CAPACITY: 6CENSUS: 6DATE:
09/17/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:10 AM
MET WITH:Licensee, Aurelio S. Trillana and Administrator, Maria L. Tiopianco-Trillana TIME VISIT/
INSPECTION COMPLETED:
04:10 PM
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Licensing Program Analyst (LPA) Antonia Alvizar-Ettima conducted an unannounced one (1) year inspection at this facility. LPA met with Licensee, Administrator and explained the reason for the visit.

LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:

At 10:45a.m. LPA and Administrator conducted a physical plant tour of the facility. The facility has one main entrance being used. Required posting are observed to be complete, current and displayed properly. The facility has an approved mitigation and infection control plan on file.

The facility is a single-story building and has four (4) bedrooms and three (3) bathrooms located in a residential community. Three (3) bedrooms are double occupancy designated for residents, and one (1) bedroom is designated for staff use. The facility is Fire Cleared for four (4) non-ambulatory residents, one (1) of which maybe bedridden and two (2) ambulatory residents. Hospice waiver for three (3) residents. Smoke detectors and carbon monoxide are hardwired, interconnected and tested for proper function. Fire extinguishers were last purchased on 05/03/2025 and observed fully charged. The most recent disaster drill was conducted on 09/05/2025. The physical environment was checked for cleanliness and condition. Walls, windows, ceilings, floors were inspected. They were found clean and good repair. The facility maintains a comfortable temperature at 73°F.

Cont. on LIC 809-C
NAME OF LICENSING PROGRAM MANAGER: Naira Margaryan
NAME OF LICENSING PROGRAM ANALYST: Antonia Alvizar-Ettima
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/17/2025
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 S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: ST. ANNE'S GOLDEN YEARS HOME
FACILITY NUMBER: 197602348
VISIT DATE: 09/17/2025
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Cont. from LIC 809

Living and dining room furniture were checked. Furniture in the living and dining rooms was observed in good repair, clean and free of hazards. Both areas were appropriately furnished and provided a comfortable environment for residents. Resident rooms are adequately furnished with appropriate furniture and lighting system. Hallways/passageways are lit. Residents have sufficient amounts of personal hygiene products which are provided by the licensee. Bathrooms were checked for cleanliness and proper operation. LPA observed the appropriate grab bars for each toilet and shower. The hot water temperature measured at a range of 106.3°F to 118.0°F. Towels and washcloths are not shared. There are enough clean linen available in stock in the linen cabinet located in the hallway. Food Service / Kitchen area was sufficiently stocked with two (2) days perishable and seven (7) days non-perishable food. Food storage and preparation areas are clean. The kitchen appeared clean and the appliances and fixtures functional. Knives and sharps are observed to be kept in the kitchen cabinet locked and inaccessible to residents. Medications: LPA observed medication in the kitchen locked cabinet and inaccessible to residents. First Aid kits are observed to be with complete tools and supplies. Laundry room is located at the side of the facility with no access from inside. The laundry room was observed to be locked and inaccessible to residents. Cleaning agents, toxins and detergents were secured. Garage is detached, locked, and inaccessible to residents. Garage is used as storage for supplies, tools and extra frozen food. Backyard of the facility has outdoor furniture, with a shaded area covered available for residents. The front and backyard passageways were clear of any obstruction. There is no body of water at the facility.

Staff records were reviewed. Staff present had criminal record clearances and associated to facility. Staff records appear to be complete and current. Resident records were reviewed. Resident’s records appeared to be complete and current.

There is no health and safety issue observed during this visit.

Exit interview conducted. A copy of this report issued.
NAME OF LICENSING PROGRAM MANAGER: Naira Margaryan
NAME OF LICENSING PROGRAM ANALYST: Antonia Alvizar-Ettima
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2025
LIC809 (FAS) - (06/04)
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