197608280-6-9-2025-29-AS-QHUH-DHGTVR-20250609150423

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197608280
Report Date: 06/09/2025
Date Signed: 06/09/2025 03:04:54 PM

Document Has Been Signed on 06/09/2025 03:04 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:	FOUR SEASONS ASSISTED LIVING CENTER LLC		FACILITY NUMBER:	197608280
ADMINISTRATOR/ DIRECTOR:	CLARIZZE PUNIT		FACILITY TYPE:	740
ADDRESS:	12120 CHANDLER BLVD		TELEPHONE:	(818) 487-0770
CITY:	NORTH HOLLYWOOD	STATE: CA	ZIP CODE:	91607
CAPACITY: 49	TOTAL ENROLLED CHILDREN: 0	CENSUS: 47	DATE:	06/09/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:08 AM
MET WITH:	Amber Leigh - Administrator		TIME VISIT/ INSPECTION COMPLETED:	03:15 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) Quoc Huynh arrived unannounced at 9:08AM for a required one year visit. The LPA met with Administrator Amber Leigh and explained the reason for the visit. Entrance interview conducted. At 9:34AM, the LPA and Administrator toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The facility is a two-story building. The following was observed: COMMON AREAS: Located on the first floor is the lobby, dining room, activity room, office, and kitchen that is attached to the Skilled Nursing Facility side of the building. Located on the second floor is the activity room and medication room. The LPA observed common areas to be clean and in good condition. There were no obstructions and/or tripping hazards throughout the facility. There were cameras in the common areas. Required postings were found in the hallway on the first floor by the office. There are fire extinguishers throughout the facility, which were serviced 05/02/2025. Emergency food and water is stored in a locked closet located on the first floor. There is one outdoor patio located on the first floor by the lobby which is utilized as a smoking area. The LPA observed a grill and outdoor furniture, with a covered shaded area for residents. There were no bodies of water observed during today’s visit. Report Continued on LIC 809-C

Kristin Heffernan	TELEPHONE: (818) 593-4493
Quoc Huynh	TELEPHONE: (323) 313-4746
	DATE: 06/09/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2025

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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Document Has Been Signed on 06/09/2025 03:04 PM - It Cannot Be Edited

Created By: Quoc Huynh On 06/09/2025 at 02:36 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. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: FOUR SEASONS ASSISTED LIVING CENTER LLC	FACILITY NUMBER: 197608280
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/09/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87303(e)(2)

Maintenance and Operation

(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in 3 out of 5 taps delivering hot water did not measure within the required range which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 06/13/2025
	Plan of Correction
1 2 3 4	Administraor will have the Maintenance Director adjust the water tempurature and send CCLD proof of the 3 units delivering hot water within the required range of 105 degrees F and 120 degrees F by POC due 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.

	Kristin Heffernan
NAME OF LICENSING PROGRAM MANAGER:

TELEPHONE: (818) 593-4493

	Quoc Huynh
NAME OF LICENSING PROGRAM ANALYST:

TELEPHONE: (323) 313-4746

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/09/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 06/09/2025 03:04 PM - It Cannot Be Edited

Created By: Quoc Huynh On 06/09/2025 at 02:36 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. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: FOUR SEASONS ASSISTED LIVING CENTER LLC	FACILITY NUMBER: 197608280
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/09/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87411(c)(1)

Personnel Requirements - General

(1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above in 1 out of 6 staff had a 1st aid/CPR that expired in 10/2023 which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/13/2025
	Plan of Correction
1 2 3 4	Administrator will have the staff send the facility their updated 1st aid/CPR training by POC due date and send the document to CCLD.

Type B

Section Cited

CCR

87458(c)(1)(A)

Medical Assessment

(c) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the licensed medical professional's diagnosis or diagnoses and results of an examination for all of the following: (A) Communicable tuberculosis. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, and record review, the licensee did not comply with the section cited above in 1 out of 10 residents did not have a TB test on file which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/13/2025
	Plan of Correction
1 2 3 4	Administrator will have the Skilled Nursing Facility complete the resident's TB test and will send CCLD proof by POC due date with the results.

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

	Kristin Heffernan
NAME OF LICENSING PROGRAM MANAGER:

TELEPHONE: (818) 593-4493

	Quoc Huynh
NAME OF LICENSING PROGRAM ANALYST:

TELEPHONE: (323) 313-4746

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/09/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2025

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 N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: FOUR SEASONS ASSISTED LIVING CENTER LLC	FACILITY NUMBER: 197608280
	VISIT DATE: 06/09/2025

NARRATIVE

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RESIDENT ROOMS: The LPA observed ten (10) randomly selected rooms on the first and second floor and no immediate health or safety hazards were observed. Restrooms were clean, with properly installed grab-bars in resident bathrooms and non-skid strips in shower tubs. Appropriate furniture was also observed in the units. Water temperature was tested throughout the units and measured between 96.3 degrees F and 107.1 degrees F, which is not within the required range of 105 degrees F and 120 degrees F.

KITCHEN: The kitchen is located on the 1st floor in the Skilled Nursing Facility. The kitchen was observed to be in compliance with Title 22 regulations. Food deliveries occur every Tuesday and Friday. There was a sufficient supply of perishable and non-perishable food. Food appeared to be of good quality. Administrator stated the residents’ meals are carted in from the kitchen to the dining room/resident rooms.

RECORDS: Records were reviewed at 10:25AM. The LPA reviewed ten (10) files for, but not limited to: admissions agreements, medical assessment, appraisals, and consent forms. LPA observed one (1) out of ten (10) resident records did not have a TB test on file. Administrator stated the resident is currently in the Skilled Nursing Facility and will have a TB test completed while they are there.

The LPA reviewed six (6) personnel records for, but not limited to: job application, health assessments, TB results, criminal record statements and clearances, and first aid/CPR certification. LPA observed one (1) staff having a 1^st Aid/CPR training which expired in 10/2023.

INFECTION CONTROL/EMERGENCY DISASTER: LPA reviewed the facility's infection control plan and Emergency Disaster plan. LPA noted that the facility is in compliance with regulation. Facility conducts emergency disaster drills as required with drills conducted monthly, with the last drill documented on 05/06/2025. The fire alarm system is tested annually with the last inspection on 03/28/2025 by the Los Angeles Fire Department.

Report Continued on LIC 809-C

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 593-4493
LICENSING EVALUATOR NAME: Quoc Huynh	TELEPHONE: (323) 313-4746
LICENSING EVALUATOR SIGNATURE:	DATE: 06/09/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2025

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 N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: FOUR SEASONS ASSISTED LIVING CENTER LLC	FACILITY NUMBER: 197608280
	VISIT DATE: 06/09/2025

NARRATIVE

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MEDICATION: Medications review began at 1:57PM. The LPA reviewed medications for five (5) residents. Medications are maintained locked and inaccessible to residents in the medication room located on the second floor. Five (5) out of five (5) resident medications reviewed were documented and stored in compliance with regulation at this time.

Five residents and four staff were interviewed. No complaints noted.

Documents obtained: LIC 500 Personnel Roster.

Pursuant to CA Title 22 Regulations, the following deficiencies were cited (Refer to LIC 809-D).

Exit interview conducted. A copy of the report and appeal rights were reviewed and provided.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 593-4493
LICENSING EVALUATOR NAME: Quoc Huynh	TELEPHONE: (323) 313-4746
LICENSING EVALUATOR SIGNATURE:	DATE: 06/09/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2025

LIC809 (FAS) - (06/04)

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