197608511-12-3-2025-31-AS-MCAA-DNZV5U-20251203150832

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197608511
Report Date: 12/03/2025
Date Signed: 12/03/2025 03:08:41 PM

Document Has Been Signed on 12/03/2025 03:08 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:	CASA BLANCA HOMECARE		FACILITY NUMBER:	197608511
ADMINISTRATOR/ DIRECTOR:	MARILOU A. ANDREAS		FACILITY TYPE:	740
ADDRESS:	17216 GOYA STREET		TELEPHONE:	(818) 366-2234
CITY:	GRANADA HILLS	STATE: CA	ZIP CODE:	91344
CAPACITY: 4		CENSUS: 2	DATE:	12/03/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	11:28 AM
MET WITH:	Angelita Cayanan		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) Michael Cava conducted an Annual Required visit and inspection of the facility. LPA met with the staff, Angelita Cayanan, and explained the reason for the visit. At approximately 11:45pm, LPA took a tour of the physical plant. The facility is a two story building, but only the first floor is licensed for operation. Only the licensee/owner occupies the second floor. No residents are allowed on the second floor. Required postings were observed in the entry area. The smoke alarms are hardwired and interconnected. The carbon monoxide detector is located in the dining room area. The fire extinguisher is located in the kitchen. Kitchen: The kitchen appliances and fixtures were functional. LPA found a sufficient amount of perishable and non-perishable food properly stored. Knives and cleaning supplies are being stored in locked drawers. Properly labeled medications were locked in one of the kitchen cabinets. Bedrooms: There are three (3) bedrooms designated for residents' use. Two (2) bedrooms are for private use, and one (1) is shared. Bedrooms were properly furnished with appropriate beddings and linens with sufficient lighting. Bathrooms: There is one (1) bathroom designated for the residents' use. The bathroom was observed to be properly supplied and had functional fixtures. Hot water temperature was measured at 111 degrees Fahrenheit. There were no cleaning supplies stored in the bathroom during the day's inspection.

NAME OF LICENSING PROGRAM MANAGER: Naira Margaryan
NAME OF LICENSING PROGRAM ANALYST: Michael Cava
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 12/03/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2025

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.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: CASA BLANCA HOMECARE	FACILITY NUMBER: 197608511
	VISIT DATE: 12/03/2025

NARRATIVE

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Common Areas: These included the living room and dining area, which is next to each other. The common areas were properly furnished with a dining room table, large enough to seat six (6). The den has a recliner, long table and fireplace, which is non-functional and screened properly. No tools present. The auditory alarms on all exit doors were on and functional at the time of the visit.

Surrounding Grounds: Entry/exits were free of obstruction. There are furniture appropriate for outdoor
use. The outdoor area was free of hazards. There is a swimming pool, which is properly fenced with a five foot gate enclosing it. There is a lock at the gate, making entry inaccessible for the residents to gain entry.

Garage: The garage is attached to the home. There is an additional refrigerator for extra perishable food storage. PPE and cleaning supplies are also maintained in the garage. Entry to the garage from the inside of the home is locked at all times, and requires a combination to unlock and gain entry.

Laundry: Washer/dryer for the laundry is in the garage.

Resident Files: LPA conducted a file review to insure forms are compliant with regulation.

Staff Files: LPA conducted a file review of staff records to insure forms and training are up to date and compliant with regulation. .

Medications: Medications are stored and locked in a cabinet. Medications and medication records were reviewed for proper storage and documentation.

Pursuant to Title 22 Division 6 of the CA Code of Regulations, there were no deficiencies observed during the visit. Exit Interview Conducted and a Copy of the Report Issued.

NAME OF LICENSING PROGRAM MANAGER: Naira Margaryan
NAME OF LICENSING PROGRAM ANALYST: Michael Cava
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 12/03/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2025

LIC809 (FAS) - (06/04)

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