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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608807
Report Date: 07/30/2025
Date Signed: 07/30/2025 03:49:23 PM

Document Has Been Signed on 07/30/2025 03:49 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:CNS DOLOROSAFACILITY NUMBER:
197608807
ADMINISTRATOR/
DIRECTOR:		MARC SAINT CLAIRFACILITY TYPE:
735
ADDRESS:22341 DOLOROSA STREETTELEPHONE:
(818) 574-5312
CITY:WOODLAND HILLSSTATE: CAZIP CODE:
91367
CAPACITY: 6CENSUS: 5DATE:
07/30/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:55 PM
MET WITH:Marc Saint ClairTIME VISIT/
INSPECTION COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Angela Barutyan arrived at the facility unannounced to conduct a required annual visit at 12:55PM. LPA Barutyan called Administrator Marc Saint Clair who arrived at 01:30PM. Entrance interview conducted.

Beginning at 01:35PM, the LPA, along with the 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:

Fire extinguishers are fully charged and were last serviced 12/17/2024. Hardwired smoke and carbon monoxide detectors and fire doors were tested at 02:33PM and all were functional at the time of the visit. LPA observed exit alarms by all doors which were functional and operating.

KITCHEN: LPA inspected the kitchen at 01:35PM. Kitchen appliances appeared clean and were in operable condition at the time of the visit. The facility had a sufficient supply of perishable and non-perishable food. Sharp objects and cleaning supplies were stored in a locked and inaccessible cabinet in the kitchen and hallway closet.

BEDROOMS: There are five (5) bedrooms of which four (4) are designated as private rooms and one (1) is designated as a shared room. Three (3) rooms have exits to the exterior. All bedrooms were furnished appropriately with clean linens, furnishings, and sufficient lighting.

Continued on LIC 809-C.

NAME OF LICENSING PROGRAM MANAGER: Kristin Heffernan
NAME OF LICENSING PROGRAM ANALYST: Angela Barutyan
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/30/2025
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 N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: CNS DOLOROSA
FACILITY NUMBER: 197608807
VISIT DATE: 07/30/2025
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RESTROOMS: There are four (4) restrooms, two (2) are attached to client rooms and two (2) are shared-use. LPA observed bathrooms to be clean, sanitary and in operating condition with grab bars and slip-resistant surfaces. Between 01:41PM-01:50PM, hot water temperatures were measured in all four (4) bathrooms and were between 107.4 F-108.0 degrees F, which is within the required range.

COMMON SPACES: Walls and flooring were checked for cleanliness and good condition. The washer and dryer are located in a laundry room in the hallway. All laundry supplies were appropriately locked at the time of the visit. Passageways were clean and clear of obstructions. LPA observed required postings throughout the common space. LPA observed a fireplace in the living room that was appropriately screened.

GARAGE AND GROUNDS: The garage is not accessible from the house and is used as a storage room. Cleaning solutions and hazardous chemicals are stored locked and inaccessible. There are additional supplies and emergency food and water. The exterior passageways were clean and clear of any obstructions. There is a covered patio area in the backyard with tables and chairs where clients can sit. No bodies of water were noted in the backyard.

RECORD REVIEW: Beginning at 01:54PM, LPA reviewed four (4) staff and five (5) out of five (5) client files for documents including but not limited to: client Admission Agreement, TB test, health screening, staff training and fingerprint clearance. All five (5) client files and four (4) staff records reviewed were in compliance with regulation at the time of the visit.



MEDICATION REVIEW: Beginning at 03:05PM, LPA reviewed medications for two (2) clients. Medications are locked inaccessible in the medication designated area in between the kitchen and living room. All medications reviewed were documented on the centrally stored medications and destruction record, however, LPA observed some medications missing start dates. Administrator immediately logged the missing start dates during the visit.

INFECTION CONTROL/EMERGENCY DISASTER PLANNING: During today's visit, LPA reviewed the facility's infection control policy as well as the emergency disaster plan. The facility’s policies and procedures as it pertains to infection control are adequate. Emergency disaster plan is updated annually as required. Emergency disaster drills are conducted monthly, with the last drill conducted on 06/19/2025.



No deficiencies cited at this time. Exit interview conducted. A copy of the report was provided.
NAME OF LICENSING PROGRAM MANAGER: Kristin Heffernan
NAME OF LICENSING PROGRAM ANALYST: Angela Barutyan
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/30/2025
LIC809 (FAS) - (06/04)
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