197608442-7-1-2026-29-AS-TBYE-DVKSNU-20260701140206

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197608442
Report Date: 07/01/2026
Date Signed: 07/01/2026 02:02:54 PM

Document Has Been Signed on 07/01/2026 02:02 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:	SVS VAN NUYS		FACILITY NUMBER:	197608442
ADMINISTRATOR/ DIRECTOR:	MAGDALENA GALVEZ		FACILITY TYPE:	775
ADDRESS:	14547 ERWIN STREET		TELEPHONE:	(818) 849-3021
CITY:	VAN NUYS	STATE: CA	ZIP CODE:	91411
CAPACITY: 45		CENSUS: 28	DATE:	07/01/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:45 AM
MET WITH:	Dulce Vallejo		TIME VISIT/ INSPECTION COMPLETED:	02:15 PM

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Licensing Program Analyst (LPA) Trevor Byrne arrived at the facility unannounced to conduct a required annual visit at 09:45 AM LPA met with Regional Director Dulce Vallejo. Entrance interview conducted and the reason for the visit was explained. All clients at this facility are vendored by the North Los Angeles Regional Center.

Beginning at approximately 09:55 AM, the LPA, along with the Regional Director toured the physical plant areas inside and outside to ensure there are no health and safety hazards and that facility is in compliance with Title 22 Regulations. The following was observed:

HALLWAY: LPA observed the hallway to be clean and free of obstructions. LPA observed fire extinguishers located throughout the hallway, all were last serviced on 04/29/2026. LPA observed the hallway to contain a locked storage closet which contained separate storage for chemicals, emergency food and water supplies, sharp objects including knives, craft supplies, and extra care supplies. LPA observed the hallway to be well lit with emergency flashlights stored near emergency exits.

OUTDOOR SPACE: The facility has four (4) emergency exit doors. LPA observed clear passageways for emergency exit use. LPA observed the back parking lot of the facility to be fenced off with a garage gate. LPA observed the back parking lot to contain a gardening area for client use and the facility’s transportation vans.

CONTINUED ON LIC 809C.

NAME OF LICENSING PROGRAM MANAGER: Kasandra Lopez
NAME OF LICENSING PROGRAM ANALYST: Trevor Byrne
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 07/01/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2026

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

FACILITY NAME: SVS VAN NUYS	FACILITY NUMBER: 197608442
	VISIT DATE: 07/01/2026

NARRATIVE

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COMMON AREAS: This included the: Conference Room, quiet room, television room, karaoke room, salon, computer room, arts and crafts room, and kitchen. LPA observed the kitchen area to be clean. Kitchen appliances appeared to be in operable condition. All common areas were observed to be clean and the furniture appeared to be in good repair. All common areas contained adequate activities for resident use. All common areas appeared to be large enough to accommodate resident activities.

BATHROOMS: There are three (3) common client bathrooms at the facility. The water temperature was measured in the client bathrooms to be 108.9, 127.9, and 131.0 degrees Fahrenheit which is outside of the range required by regulation. All client bathrooms were equipped with grab bars located near the client toilets. All grab bars were properly secured. All client bathrooms were observed to be clean and free of odors.

SECOND FLOOR: LPA observed the second floor of the facility to contain five (5) staff offices, the employee break room, and the network closet. Additionally, the second floor contained additional PPE supplies and a complete first aid kit for the facility. The facility’s carbon monoxide alarm was tested at 10:17 AM and functioned properly at the time of the visit. The facility’s fire alarms were last inspected on 05/12/2026 and were certified through 01/18/2028.

RECORD REVIEW: Record review began at 10:36 AM. Staff and client records were reviewed for documents including, but not limited to: health screening, TB test, staff training records, fingerprint clearance, client physician's report, needs and service appraisal, consent forms, and personal rights. Five (5) staff files were reviewed. All staff files contained all required documentation and trainings. Five (5) client files were reviewed. One (1) client file was observed to be missing proof of their ambulatory status. LPA notified the Regional Director who agreed to obtain this information from the client’s physician.

MEDICATION REVIEW / CASH RESOURCE REVIEW: This facility does not handle client medication or cash resources. No medication or cash resource review was conducted during today’s visit.

INFECTION CONTROL / EMERGENCY DISASTER PLANNING: During today’s visit, the LPA reviewed the facility's infection control plan and the facility’s emergency disaster plan. The facility’s policies and procedures as they pertain to infection control are adequate. Emergency disaster drills are conducted quarterly; the facility’s last emergency disaster drill was conducted on 04/13/2026. The facility’s emergency disaster plan is up to date and is adequate. Both the infection control plan and the emergency disaster plan are reviewed/updated annually by the facility’s Director. CONTINUED ON LIC 809C.

NAME OF LICENSING PROGRAM MANAGER: Kasandra Lopez
NAME OF LICENSING PROGRAM ANALYST: Trevor Byrne
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 07/01/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2026

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: SVS VAN NUYS	FACILITY NUMBER: 197608442
	VISIT DATE: 07/01/2026

NARRATIVE

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INTERVIEWS: LPA interviewed three (3) clients and three (3) staff members. All clients interviewed stated that facility staff are kind and that the facility offers a good variety of engaging activities. No clients interviewed had concerns with the facility. All staff members interviewed were knowledgeable on their roles and responsibilities, the resident’s rights, the forms of abuse, and the appropriate reporting procedures for suspected abuse.

During today’s visit LPA obtained a copy of the facility’s LIC 500, client roster, emergency disaster plan, and current liability insurance.

Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D). Exit interview conducted and copy of the report was issued and appeal rights provided.

NAME OF LICENSING PROGRAM MANAGER: Kasandra Lopez
NAME OF LICENSING PROGRAM ANALYST: Trevor Byrne
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 07/01/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2026

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 07/01/2026 02:02 PM - It Cannot Be Edited

Created By: Trevor Byrne On 07/01/2026 at 01:33 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: SVS VAN NUYS	FACILITY NUMBER: 197608442
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/01/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

82088(e)(1)

Fixtures, Furniture, Equipment, and Supplies

(1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 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 as the water temperature in two resident sinks were measured at 131.0 and 127.9 degrees Fahrenheit which poses an immediate health and safety risk to clients in care.
	POC Due Date: 07/02/2026
	Plan of Correction
1 2 3 4	Regional Director agreed to submit proof of an appropriate water temperature measured at all three resident faucets to CCLD no later than 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.

	Kasandra Lopez
NAME OF LICENSING PROGRAM MANAGER:

	Trevor Byrne
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/01/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2026

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 07/01/2026 02:02 PM - It Cannot Be Edited

Created By: Trevor Byrne On 07/01/2026 at 01:34 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: SVS VAN NUYS	FACILITY NUMBER: 197608442
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/01/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

82069(b)(4)

82069 Client Medical Assessments (b) The medical assessment shall include the following: (4) A determination of the client's ambulatory status, as defined by Section 82001(n). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review the Licensee did not comply with the section cited above as one client file was missing proof of the ambulatory status of the client which poses a potential health and safety risk to clients in care.
	POC Due Date: 07/15/2026
	Plan of Correction
1 2 3 4	Regional Director agreed to submit proof of the identified client's ambulatory status signed by a physician to CCLD no later than 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.

	Kasandra Lopez
NAME OF LICENSING PROGRAM MANAGER:

	Trevor Byrne
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/01/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2026

LIC809 (FAS) - (06/04)

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