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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607891
Report Date: 05/29/2025
Date Signed: 05/29/2025 03:03:56 PM

Document Has Been Signed on 05/29/2025 03:03 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.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:CNS MARTHAFACILITY NUMBER:
197607891
ADMINISTRATOR/
DIRECTOR:		MARC SAINT CLAIRFACILITY TYPE:
735
ADDRESS:19443 MARTHA STREETTELEPHONE:
(818) 342-9443
CITY:TARZANASTATE: CAZIP CODE:
91356
CAPACITY: 6CENSUS: 4DATE:
05/29/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:45 PM
MET WITH:Marc St. ClairTIME VISIT/
INSPECTION COMPLETED:
03:00 PM
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At approximately 12:45 p.m. on 05/29/25, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced annual inspection. LPA met with the administrator and disclosed the reason for the visit.

The facility was last visited on 05/28/24 for an annual inspection. It is a single story building with five (05) bedrooms, five (05) bathrooms, kitchen, garage, common areas, and outdoor areas. It has an approved fire clearance for six (06) nonambulatory residents, of which four (04) may be bedridden. Surveillance cameras were observed in common and exterior areas. The front access is gated and requires a PIN code for entry. The front and back yards were well maintained with gardened areas. A centralized auditory alarm system was operational. Fire sprinklers were located throughout the facility.

At the main entrance and office area, LPA observed postings for personal rights, emergency contacts, emergency disaster plan, confidential complaint contacts, administrator certificates, and the facility license. The screening station at the front contained a sign-in sheet and hand sanitizer.

LPA observed an adequate supply of perishable and non-perishable foods in the kitchen. Cabinet spaces, pantries, and snack caches were all personalized per client. Client pantries also had personalized menus posted based on dietary plans. An activity calendar was posted. The stove hood was clean. Appliances were in good condition. Sharps, cleaning solutions, and detergents were locked in a pantry near the kitchen as well as underneath the sink. A medication cabinet near the kitchen was locked. Two (02) washing machines and two (02) dryers were located adjacent to the kitchen. Both were made inaccessible.

NAME OF LICENSING PROGRAM MANAGER: Naira Margaryan
NAME OF LICENSING PROGRAM ANALYST: Nicholas Reed
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/29/2025
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.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: CNS MARTHA
FACILITY NUMBER: 197607891
VISIT DATE: 05/29/2025
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The facility has five (05) bedrooms. Four (04) bedrooms are private, and Bedroom #1 is a shared room. All bedrooms contained a chair, lamp, nightstand, storage, call buttons, and a bed with adequate bedding. All furnishings were clean and in good condition. All bedrooms with emergency exits were unlocked and free of debris. The fireplace in Bedroom #1 was disconnected from the gas line and appropriately covered. The facility has five (05) bathrooms. All bathrooms contained liquid soap, paper towels, trash can with a tight-fitting lid, grab bars near the toilet and shower, and a non-skid mat or non-skid surface in the shower. At approximately 1:15 p.m. LPA measured the water temperature in the private bathroom to Bedroom #1 to be 109.8 degrees Fahrenheit.

Walls, floors, windows, screens, and blinds were clean and in good repair. At 1:35 p.m. LPA measured the room temperature to be 73 degrees Fahrenheit. The living room contained board games, reading material, television, art supplies, exercise equipment, and furniture in good repair. Near the living room, a complete first aid kit, a bloodborne first aid kit, a fully-charged fire extinguisher, and an Automated External Defibrillator were all mounted along a wall. The fire extinguisher was last inspected on 12/17/24. The garage was locked and stored extra resident supplies and emergency food supplies. LPA observed multiple covered patio areas in the rear of the facility. The patio contained furniture in good condition, exercise equipment, a basketball court, a gas grill, a generator, and a maintained back yard area. A separated office area was locked and stored confidential files. Two (02) out of two (02) emergency exit paths were free from obstructions. Evacuation routes were posted.

At approximately 1:45 p.m., smoke and carbon monoxide detectors were tested and operational. At 1:50 p.m., the house telephone was called and deemed operational. At 1:55 p.m., the facility vehicle was inspected and deemed operational. The vehicle had a driver log, first aid kit, and fire extinguisher.

At approximately 2:00 p.m. LPA reviewed client and personnel files. All files were current and available for audit.

During today’s inspection, the facility was observed to be in compliance with all Title 22 regulations. No immediate health and safety risks were observed.

Exit interview conducted. Copy of report provided.

NAME OF LICENSING PROGRAM MANAGER: Naira Margaryan
NAME OF LICENSING PROGRAM ANALYST: Nicholas Reed
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/29/2025
LIC809 (FAS) - (06/04)
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