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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197606451
Report Date: 04/03/2025
Date Signed: 04/03/2025 02:00:44 PM

Document Has Been Signed on 04/03/2025 02:00 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:PARTNERS FOR POTENTIAL, INC.FACILITY NUMBER:
197606451
ADMINISTRATOR/
DIRECTOR:		LISA ANN WILLIAMSENFACILITY TYPE:
775
ADDRESS:6255 VAN NUYS BOULEVARDTELEPHONE:
(818) 997-0819
CITY:VAN NUYSSTATE: CAZIP CODE:
91401
CAPACITY: 60CENSUS: 35DATE:
04/03/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:40 AM
MET WITH:Lisa Ann Williamsen - Chief Executive OfficerTIME VISIT/
INSPECTION COMPLETED:
02:05 PM
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Licensing Program Analyst (LPA) Erica Mosley arrived at the Adult Day Program (ADP) unannounced to conduct a required annual visit at 9:40 a.m. The LPA met with Chief Executive Officer (CEO), Lisa Ann Williamsen and explained the reason for the visit. Upon arrival, there were zero (0) consumers and six (6) Administrative staff in the building. The day program’s consumers are community based. No consumers were observed on the day of the visit. On today's visit the day program has thirty five (35) consumers and fourteen (14) staff in the community. The program currently operates from 7:30 a.m. to 5:00 p.m. and consumer operations from 8:00 a.m. to 2:00 p.m. The day program is staffed with a 1:3 staff to consumer ratio.

At 10:02 a.m., the LPA and CEO toured the physical plant to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The LPA observed fire extinguishers throughout the facility, which were last serviced on 11/11/2024. The last emergency disaster drill took place on 03/20/2025 and are conducted monthly. Consumers keep personal belongings in individual lockers. There is a sufficient supply of drinking water, emergency water and emergency food. Cleaning supplies, sharps and knives are stored in the locked staff room / kitchen. The facility maintained a comfortable temperature. The LPA observed required postings. Entry/exits were free of obstruction. The facility does not handle medications, therefore there are no provisions for a locked storage space.

(PAGE 1) ...Report will continue on LIC809-C PAGE 2...

NAME OF LICENSING PROGRAM MANAGER: Kasandra Lopez
NAME OF LICENSING PROGRAM ANALYST: Erica Mosley
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/03/2025
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)
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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: PARTNERS FOR POTENTIAL, INC.
FACILITY NUMBER: 197606451
VISIT DATE: 04/03/2025
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(PAGE 2) (Report Continued from LIC 809 PAGE 1...)

Common Activity Space: The facility is located on the second floor of a two story structure with an elevator, conference room, four (4) administrative offices, one (1) large classroom for consumer use with lockers, computers, games and activities, four (4) bathrooms, locked staff kitchen with a refrigerator, and a locked storage room. All rooms were properly furnished. The LPA did not observe any obstructions or hazards during the inspection. The program site appeared to be clean, sanitary, and in good repair at the time of the visit.

Outdoor Space: Passageways to the lobby on the second floor were free and clear from obstruction.


Staff room/Kitchen: The kitchen area was clean and in good condition. Cleaning solutions, toxins, chemicals and other hazardous items were inaccessible and locked away in the staff room/ kitchen. Sharps and knives were observed locked and inaccessible to consumers.

Restrooms: Restrooms were clean, sanitary and in operating condition. There are four (4) total restrooms. Restrooms were observed to be equipped with hand soap and paper towels. The restrooms hot water temperature is regulated with an instant electric water heater that is set to 108.0 degrees Fahrenheit. Signs are posted throughout all four (4) restrooms to promote hand washing. The hot water temperature in the restrooms was tested at 10:05 am and measured at 108.0 degrees Fahrenheit within the required range.

Record Review: At 10:20 a.m. a review of facility files was initiated. Infection Control / Emergency disaster planning: During today’s visit LPA Mosley reviewed the facility’s infection control practices and the facilities emergency disaster plan. The facilities policies and procedures as it pertains to infection control and emergency preparedness are sufficient.

Personnel Records were reviewed beginning at 10:21 a.m. Six (6) Personnel files including the CEO's file were reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, first aid/CPR training, and all the appropriate training. All records were in order.

Consumer Records were reviewed beginning at 11:11 a.m. Six (6) Consumer files were reviewed for, but not limited to, the following: signed admission agreements, current medical assessments with TB results, LIC627(c) Consent for Treatment form, and current needs and services plan. All records were in order.

(PAGE 2) ...Report will continue on LIC809-C PAGE 3...

NAME OF LICENSING PROGRAM MANAGER: Kasandra Lopez
NAME OF LICENSING PROGRAM ANALYST: Erica Mosley
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/03/2025
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 N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: PARTNERS FOR POTENTIAL, INC.
FACILITY NUMBER: 197606451
VISIT DATE: 04/03/2025
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(PAGE 3) (Report Continued from LIC 809 PAGE 2...)

Interview: During today's visit, starting at 1:15 p.m. the LPA interviewed three (3) staff. Since the day program’s consumers are community based no consumers were available to interview. Interviews revealed that staff are knowledgeable in consumer rights, different forms of abuse and reporting procedures.

LPA obtained the following documents - Consumer roster, Staff roster, and copy of the Limited Liability insurance.

During today's inspection, the facility is in compliance with Title 22 regulations. No citations issued. Exit interview conducted. Copy of report provided.

NAME OF LICENSING PROGRAM MANAGER: Kasandra Lopez
NAME OF LICENSING PROGRAM ANALYST: Erica Mosley
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/03/2025
LIC809 (FAS) - (06/04)
Page: 4 of 4