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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197606909
Report Date: 04/28/2025
Date Signed: 04/28/2025 01:33:17 PM

Document Has Been Signed on 04/28/2025 01:33 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:PEOPLE CREATING SUCCESS, INC. PCS-PARTHENIAFACILITY NUMBER:
197606909
ADMINISTRATOR/
DIRECTOR:		JACOB PASCASIOFACILITY TYPE:
735
ADDRESS:22005 PARTHENIA AVENUETELEPHONE:
(747) 242-1038
CITY:WEST HILLSSTATE: CAZIP CODE:
91304
CAPACITY: 5CENSUS: 4DATE:
04/28/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:15 AM
MET WITH:Jacob Pascasio, AdministratorTIME VISIT/
INSPECTION COMPLETED:
02:00 PM
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At 10:10 AM, Licensing Program Analyst (LPA) Huma Rahimi arrived at this facility to conduct a Required Annual Inspection. LPA rang the bell and no one responded. LPA called the facility's phone number and no one responded. LPA contacted the Administrator and left a voicemail. LPA knocked the facility's door and waited for additional ten (10) minutes. At 10:25 AM, the Administrator Jacob Pascasio granted access to LPA. LPA explained the reason for the visit. At 10:35 AM, LPA and the Administrator toured the facility and observed the following:

The facility is a single story building with four (04) bedrooms, two (02) bathrooms, kitchen, garage, common areas, and outdoor areas. It has an approved fire clearance for 5 non-ambulatory clients. Facility is operating level 4 clients.

Kitchen: At approximately 10:36 AM, LPA toured the kitchen area and observed enough supplies of staple non-perishable for minimum 1 week and perishable for 2 days at the facility. Facility stores the knives, sharps, first aid kit, emergency supply of food and water, client's medications and facility records in a locked cabinet by the kitchen. LPA observed two (2) fire extinguishers one (1) is located by the kitchen and the second is in a hallway fully charged with a serviced date of 03/12/2025.

Bedrooms: LPA observed total of four (4) bedrooms designated for clients use. All bedrooms are properly furnished, clean and have appropriate bedding and linens.

Bathrooms: LPA observed two (2) bathrooms and both appeared to be clean and in good repair. Properly supplied with toilet papers, soap and paper towels. LPA observed appropriate grab bar and client's bathroom had non-skid mat. Hot water temperature measured at 111.4°F. Continue on LIC809-C

NAME OF LICENSING PROGRAM MANAGER: Nichelle Gillyard
NAME OF LICENSING PROGRAM ANALYST: Huma Rahimi
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/28/2025
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 S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: PEOPLE CREATING SUCCESS, INC. PCS-PARTHENIA
FACILITY NUMBER: 197606909
VISIT DATE: 04/28/2025
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Common Areas: The facility maintains a comfortable temperature at 68°F. The living room and dining area appeared clean and were properly furnished. The living room has a television, comfortable furniture. No obstructions and or tripping hazards throughout the facility. The garage is currently being used for storage and laundry. Laundry detergents, cleaning agents and other toxins are locked away.

Smoke and Carbon Monoxide Detectors: The smoke and carbon monoxide detectors were tested by the a staff at 1:00pm. and were observed operational.

Backyard: LPA observed all emergency exit paths were free from obstructions. Two (2) exit gates were unlocked with self-closing latches. LPA observed appropriate outdoor furniture, with a covered shaded area for clients.


Between 11:30 AM to 12:30 PM, LPA reviewed records of four (4) clients and observed that two (2) out of four (4) clients did not have TB test results on file. LPA asked the Administrator and the Administrator admitted that no TB results were available. Furthermore, LPA was not provided with staff files. LPA was informed that all staff files are not in the facility to review and are at the office due to the facility's locking/securing mechanism. LPA waited for additional thirty (30) minutes for the files to arrive for review; however, the files were still not present.

Administrative: LPA collected Certificate of Liability Insurance, and LIC500.

Deficiencies are issued during today's visit. Appeal rights explained.

Exit interview conducted and copy of this report signed and delivered.




NAME OF LICENSING PROGRAM MANAGER: Nichelle Gillyard
NAME OF LICENSING PROGRAM ANALYST: Huma Rahimi
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2025
LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 04/28/2025 01:33 PM - It Cannot Be Edited


Created By: Huma Rahimi On 04/28/2025 at 12:41 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: PEOPLE CREATING SUCCESS, INC. PCS-PARTHENIA
FACILITY NUMBER: 197606909

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/28/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80069(c)(1)
80069 Client Medical Assessments (c) The medical assessment shall include the following: (1) The results of an examination for communicable tuberculosis and other contagious/infectious diseases.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on clients record review the licensee did not comply with the section cited by not making sure to obtain TB clearance for two (2) out of four (4) clients which poses a potential health and safety risk to clients in care.
POC Due Date: 05/05/2025
Plan of Correction
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Administrator shall obtain TB as required in title 22 for two (2) out of four (4) clients. A copy shall be provided to LPA by POC due date.
Type B
Section Cited
CCR
80066(c)
80066 - Personnel Records. Removal of records: During normal business hours, upon demand, all personnel records shall be available to the licensing agency to inspect, audit, and copy. Records may be removed if necessary for copying. Personnel records were not available for review at time of visit.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above in 19 out of 19 staff records to be available for audit and review which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/05/2025
Plan of Correction
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Administrator agrees to maintain personnel records of staff and make them available for review upon request of CCL personnel during normal business hours. Administrator will inform LPA via e-mail of all personnel files available at the facility to clear the dificiency by the POC due 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.
Nichelle Gillyard
NAME OF LICENSING PROGRAM MANAGER:
Huma Rahimi
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/28/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/28/2025


LIC809 (FAS) - (06/04)
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