197604143-4-20-2026-31-AS-MAGN-DTBU6H-20260420151823

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197604143
Report Date: 04/20/2026
Date Signed: 04/20/2026 03:22:31 PM

Document Has Been Signed on 04/20/2026 03:22 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:	HEADWAY HOUSE, INC.		FACILITY NUMBER:	197604143
ADMINISTRATOR/ DIRECTOR:	LENA REINHOLDS		FACILITY TYPE:	735
ADDRESS:	8500 SHIRLEY AVENUE		TELEPHONE:	(818) 772-2266
CITY:	NORTHRIDGE	STATE: CA	ZIP CODE:	91324
CAPACITY: 6		CENSUS: 4	DATE:	04/20/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:30 AM
MET WITH:	Stanley Kaniel- Administrator		TIME VISIT/ INSPECTION COMPLETED:	03:30 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) Mariana Agban conducted an Annual Required visit and inspection of the facility. LPA met with the staff and later with the new Administrator Stanley Kaniel, and explained the reason for the visit. At approximately 09:40 a.m., with the assistance of the staff, LPA took a tour of the physical plant. Required postings were observed in the entry area. LPA tested the smoke detectors and carbon monoxide detectors and they were functional. The fire extinguisher is located in the living area. The charge date is September 05,2025 Kitchen: The kitchen appliances and fixtures were functional. LPA found a sufficient amount of perishable and non-perishable food at the facility; properly stored. Knives were stored in a locked cabinet under the kitchen sink. Bedrooms: The facility has four (4) Bedrooms. All four bedrooms, in use by clients, were properly furnished with appropriate bedding and linens with sufficient lighting. Bathrooms: There are two (2) bathrooms designated for clients' use. Both bathrooms were properly supplied and had functional fixtures. Hot water temperature was measured from the bathroom sink at 107.8 and 108.1 degrees Fahrenheit. No cleaning supplies or hazardous items were present in each bathroom during the inspection. Common Areas: These included the living room and dining area. The common areas were properly furnished. Properly labeled medications were locked in one of the dining cabinets. The fireplace is non-functional. No key to the fireplace, and fireplace tools were not present. The dining room table is large enough to sit the capacity of the facility. Seating such as couches where in good repair and sit the capacity of the facility. Surrounding Grounds: Entry/exits were free of obstruction. There was furniture appropriate for outdoor use. The outdoor area was free of hazards. The gates at both sides of the home were checked to ensure no locks were installed, and that exits and passageways were clear for emergency evacuation. (Continue on 809C)

NAME OF LICENSING PROGRAM MANAGER: Mary G Flores
NAME OF LICENSING PROGRAM ANALYST: Mariana Agban
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/20/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/20/2026

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 S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: HEADWAY HOUSE, INC.	FACILITY NUMBER: 197604143
	VISIT DATE: 04/20/2026

NARRATIVE

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Laundry Area/ Garage: LPA observed the laundry area located in the garage. The Garage is attached to the facility and is currently being used for extra storage, there is an extra refrigerator, and a freezer. There were no chemicals/hazardous items located in the garage.
Client Files: LPA conducted a file review of resident records to ensure compliance with licensing forms. LPA observed that C2 is currently in hospice since Jan of 2026. Records Review indicated that the facility doesn't have hospice wavier for any clients.
Staff Files: LPA also conducted a file review of staff records to ensure forms and training are up to date and compliance with licensing forms.
Medications: Medication and Medication Records were reviewed for proper documentation. LPA observed incomplete medication records for four out of four clients.
Cash Resources: Documents for cash resources incomplete. LPA only observed C1's LIC 405 form.
Temperature: The facility maintains a comfortable temperature of 77 degrees Fahrenheit.

Pursuant to Title 22 Division 6 of the CA Code of Regulations, deficiencies cited on 809D. Appeal Rights explained and copy of this report signed and delivered.

NAME OF LICENSING PROGRAM MANAGER: Mary G Flores
NAME OF LICENSING PROGRAM ANALYST: Mariana Agban
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/20/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/20/2026

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 04/20/2026 03:22 PM - It Cannot Be Edited

Created By: Mariana Agban On 04/20/2026 at 02:11 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., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: HEADWAY HOUSE, INC.	FACILITY NUMBER: 197604143
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/20/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

85075.1(a)(1)

The licensee has received a facility hospice care waiver from the Department This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review and interview the licensee did not comply with the section cited above. C2 is currently receiving hospice services and the facility does not have hospice wavier which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/27/2026
	Plan of Correction
1 2 3 4	Administrator agreed to apply for hospice wavier for C2 by the POC date.

Type B

Section Cited

CCR

80026(h)

(h) Each licensee shall maintain accurate records of accounts of cash resources, personal property, and valuables entrusted to his/her care, including, but not limited to the followin ...This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview and record review, the licensee did not comply with the section cited above. There were no records of accounts of cash resources for four out four clients which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/27/2026
	Plan of Correction
1 2 3 4	Administrator agreed to provide accurate records of accounts of cash resources for 4 clients by the POC 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.

	Mary G Flores
NAME OF LICENSING PROGRAM MANAGER:

	Mariana Agban
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/20/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/20/2026

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 04/20/2026 03:22 PM - It Cannot Be Edited

Created By: Mariana Agban On 04/20/2026 at 02:30 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., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: HEADWAY HOUSE, INC.	FACILITY NUMBER: 197604143
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/20/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1565(c)

Other Provisions

(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of individuals served by the facility is not required during a drill. While a facility may provide an opportunity for individuals served by the facility to participate in a drill, it shall not require that participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and, if applicable, the names of staff participating in the drill. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date:
	Plan of Correction
1 2 3 4

Type B

Section Cited

CCR

80075(k)(7)

Health-Related Services

(k) The following requirements shall apply to medications which are centrally stored: (k) The following requirements shall apply to medications which are centrally stored: (7) The licensee shall ensure the maintenance, for each client, of a record of centrally stored prescription medications which is retained for at least one year and includes the following: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Mary G Flores
NAME OF LICENSING PROGRAM MANAGER:

	Mariana Agban
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/20/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/20/2026

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 04/20/2026 03:22 PM - It Cannot Be Edited

Created By: Mariana Agban On 04/20/2026 at 02:58 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., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: HEADWAY HOUSE, INC.	FACILITY NUMBER: 197604143
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/20/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80075(k)(7)

(k) The following requirements shall apply to medications which are centrally stored: (k) The following requirements shall apply to medications which are centrally stored: (7) The licensee shall ensure the maintenance, for each client, of a record of centrally stored prescription medications which is retained for at least one year and includes the following: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above. There were incomplete medication records for 4 out of 4 clients which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/04/2026
	Plan of Correction
1 2 3 4	Administrator agreed to provide copy of complete medication records for 4 out 4 clients by the POC date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Mary G Flores
NAME OF LICENSING PROGRAM MANAGER:

	Mariana Agban
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/20/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/20/2026

LIC809 (FAS) - (06/04)

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