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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607355
Report Date: 02/19/2025
Date Signed: 02/19/2025 05:33:52 PM

Document Has Been Signed on 02/19/2025 05:33 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:THREE SYCAMORES ON GOULDFACILITY NUMBER:
197607355
ADMINISTRATOR/
DIRECTOR:		MARK YULEFACILITY TYPE:
740
ADDRESS:4701 GOULD AVENUETELEPHONE:
(818) 952-0491
CITY:LA CANADASTATE: CAZIP CODE:
91011
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 3DATE:
02/19/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:40 AM
MET WITH:Assistant Administrator, Sean Draeco Abalajon and Administrator, Mark YuleTIME VISIT/
INSPECTION COMPLETED:
04:30 PM
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Licensing Program Analyst (LPA) Antonia Alvizar-Ettima conducted an unannounced Required One (1) year inspection to the facility. LPA met with Assistant Administrator and Administrator and explained the reason for the visit. Administrator, Yule indicated not being able to stay for today’s visit and authorized Assistant Administrator to sign the report.

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

At 10:05p.m. a tour of the physical plant was conducted. There is only one entrance being utilized at the facility. Living and dining room furniture were checked. The living room is neat and clean. The dual carbon/smoke detectors are interconnected and observed to be operational. Fire extinguishers with service date of 01/03/2025 are located thorough out the facility.

The facility has five (05) bedrooms and three (03) bathrooms currently occupying three (03) residents. Three (03) rooms are private room and two (02) rooms are empty.

The backyard of the facility has outdoor furniture with a covered shaded area for residents. There is no body of water at the facility. There is also a shed at the backyard.

Laundry area is located next to detached garage, laundry detergents, cleaning agents and other toxins were observed to be locked.

Food Service/Kitchen area was sufficiently stocked with two (02) days of perishable and seven (07) days of non-perishable food. Knives and sharp objects were observed to be locked and inaccessible to residents.

Cont. on LIC 809-C

Naira MargaryanTELEPHONE: (818) 596-4368
Antonia Alvizar-EttimaTELEPHONE: (818) 383-6108
DATE: 02/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/19/2025
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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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: THREE SYCAMORES ON GOULD
FACILITY NUMBER: 197607355
VISIT DATE: 02/19/2025
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Residents rooms are adequately furnished with appropriate furniture and lighting system.

The bathroom was checked for cleanliness and proper operation. LPA observed the appropriate grab bars in the shower and toilet. The hot water temperature was measured at 111.8 degrees. There was enough clean linen available in stock at the cabinet.

LPA observed medication in the kitchen cabinet to be locked and inaccessible to residents. There are two (02) complete first aid kit.

Resident Files: A file review of resident records to insure compliance of licensing forms.

Staff Files: A file review of staff records to insure forms and training are up to date and compliance with licensing forms.


Pursuant to Title 22 Division 6 of the CA Code of Regulations, deficiencies observed cited on LIC809-D during the visit.

Exit Interview Conducted / A Copy of the Report was provided to Assistant Administrator, Sean Abalajon.

SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Antonia Alvizar-EttimaTELEPHONE: (818) 383-6108
LICENSING EVALUATOR SIGNATURE:

DATE: 02/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/19/2025
LIC809 (FAS) - (06/04)
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