<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608694
Report Date: 03/17/2025
Date Signed: 03/17/2025 04:52:44 PM

Document Has Been Signed on 03/17/2025 04:52 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:VILLAGE AT SHERMAN OAKS, THEFACILITY NUMBER:
197608694
ADMINISTRATOR/
DIRECTOR:		GRACE HARTNETTFACILITY TYPE:
740
ADDRESS:5450 VESPER AVETELEPHONE:
(818) 994-7900
CITY:SHERMAN OAKSSTATE: CAZIP CODE:
91411
CAPACITY: 179TOTAL ENROLLED CHILDREN: 0CENSUS: 172DATE:
03/17/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:57 AM
MET WITH:Grace HartnettTIME VISIT/
INSPECTION COMPLETED:
05:00 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 Analysts (LPAs) Quoc Huynh and Trevor Byrne arrived at the facility unannounced to conduct a required annual visit at 09:57 AM. LPAs met with facility Administrator Grace Hartnett. Entrance interview conducted and the reason for the visit was explained.

The facility has several floors divided into separate areas of memory care, assisted living, and independent living occupants. The facility is licensed in Building A on the 1st, 2nd and 3rd floor and In Building B, only on the 2nd floor. There were no obstructions and/or tripping hazards throughout the facility. The facility maintains a comfortable temperature at approximately 72 degrees.

Beginning at 10:46 AM, the LPAs, along with facility Administrator 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:

BEDROOMS: There are One-Hundred sixty-three (163) bedrooms in the facility. LPAs and facilityAdministrator toured seventeen (17) resident rooms. All resident rooms were observed to be furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting. LPAs observed one (1) resident room to contain a ripped balcony screen door. LPAs tested the emergency pull cords in two (2) resident rooms. The staff's response time did not exceed 10 minutes.

BATHROOMS: All resident bedrooms in the facility have attached private bathrooms and shared bathrooms are located throughout the common areas of the facility. All bathrooms LPAs inspected were observed to be clean and in good repair and all were equipped with nonskid surfaces. Grab bars were observed in all showers and near all toilets, all were properly secured. The water temperature was measured between 107.8 and 114.6 degrees Fahrenheit, which is in compliance with regulation. Continued on LIC 809C.
Kasandra LopezTELEPHONE: (818) 596-4343
Trevor ByrneTELEPHONE: 747-444-6104
DATE: 03/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/17/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4
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: VILLAGE AT SHERMAN OAKS, THE
FACILITY NUMBER: 197608694
VISIT DATE: 03/17/2025
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
26
27
28
29
30
31
32
COMMON AREAS: LPAs observed cameras to be located throughout the facility’s hallways. LPAs observed the facility’s activities room, libraries, theater, salon, art gallery, and gym. All common area rooms were observed to be clean and in good repair. All furniture observed was in adequate condition and was free from rips and tears. LPAs observed locked janitorial closets and laundry rooms throughout the facility’s hallways. The facility has adequate indoor space to accommodate resident’s activities. LPAs observed the entryway of the facility to contain an fireplace. It is appropriately screened and contains no tools. LPAs observed a fire extinguishers located throughout the facility to be last serviced on 08/28/2024. LPAs tested the facility’s fire alarm system at 01:50 PM. All alarms and fire doors observed functioned properly at the time of the test.

OUTDOOR SPACE: LPAs observed the outdoor spaces of the facility. LPAs observed two (2) terraces and one (1) outdoor yard. LPAs observed the outdoor yard to contain an appropriately fenced off pool, a greenhouse, and planter boxes utilized for resident activities. LPAs observed one (1) of the terraces to have two (2) window screen frames that were observed to be in disrepair.

KITCHEN/DINING ROOM: The LPAs observed the kitchen area to be clean. Kitchen appliances were in operable condition. The facility has a sufficient supply of two (2) days perishable and seven (7) days non-perishable food. LPAs observed the kitchen to contain adequate emergency food supplies. LPAs observed the kitchen entrance to be under staff observation. LPAs observed the dining room to be clean and properly furnished at the time of the visit. The dining room contains adequate seating and tables for resident use.

MEDICATION REVIEW: Medication review began at 02:00 PM. Medications are stored centrally and securely in two (2) medication rooms located in each wing of the facility. LPAs observed medications for seven (7) residents. One (1) resident’s medications were observed to be documented incorrectly on their centrally stored medication and destruction record sheets.

INTERVIEWS: LPAs interviewed five (5) residents. All residents interviewed stated that the staff treat them well and are attentive to their needs. No residents interviewed had concerns with the facility.

Continued on LIC 809C.

SUPERVISOR'S NAME: Kasandra LopezTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Trevor ByrneTELEPHONE: 747-444-6104
LICENSING EVALUATOR SIGNATURE:

DATE: 03/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/17/2025
LIC809 (FAS) - (06/04)
Page: 2 of 4
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: VILLAGE AT SHERMAN OAKS, THE
FACILITY NUMBER: 197608694
VISIT DATE: 03/17/2025
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
26
27
28
29
30
31
32
During today’s visit LPAs obtained a copy of the facility’s resident roster.

Due to time constraints LPAs will return at a later date to conduct employee interviews, conduct resident and staff file review, review the facility’s emergency disaster plan and infection control plan, and to obtain copies of the facility’s LIC 500 and 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.

SUPERVISOR'S NAME: Kasandra LopezTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Trevor ByrneTELEPHONE: 747-444-6104
LICENSING EVALUATOR SIGNATURE:

DATE: 03/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/17/2025
LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 03/17/2025 04:52 PM - It Cannot Be Edited

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: VILLAGE AT SHERMAN OAKS, THE
FACILITY NUMBER: 197608694

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/17/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Deficiency Dismissed
Section Cited
CCR
87465(h)(6)
87465 Incidental Medical and Dental Care
(h) The following requirements shall apply to medications which are centrally stored:
(6) The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least one year and includes:
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 resident's centrally stored medication and destruction record sheet contained inaccurate and out of date information which poses a potential health, risk to persons in care.
POC Due Date: 03/31/2025
Plan of Correction
1
2
3
4
Licensee will submit an accurate CSMDR for the identified resident to CCLD no later than POC due date.
Type B
Section Cited
CCR
87303(c)
87303 Maintenance and Operation
(c) All window screens shall be clean and maintained in good repair.
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 LPAs observed three window screens/window screen frames were observed to be in disrepair which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/31/2025
Plan of Correction
1
2
3
4
Licensee will complete appropriate repairs to the identified window screens/frames and will submit proof of repairs to CCLD no later than POC due date.
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 LopezTELEPHONE: (818) 596-4343
Trevor ByrneTELEPHONE: 747-444-6104

DATE: 03/17/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/17/2025

LIC809 (FAS) - (06/04)
Page: 4 of 4