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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609500
Report Date: 07/31/2026
Date Signed: 07/31/2026 03:19:54 PM

Document Has Been Signed on 07/31/2026 03:19 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
Lookup Error,
, CA
FACILITY NAME:DEVONSHIRE ELDERLY CAREFACILITY NUMBER:
197609500
ADMINISTRATOR/
DIRECTOR:		BANGASH, FARAHFACILITY TYPE:
740
ADDRESS:17441 DEVONSHIRE STREETTELEPHONE:
(310) 955-0674
CITY:NORTHRIDGESTATE: CAZIP CODE:
91325
CAPACITY: 6CENSUS: 6DATE:
07/31/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:45 AM
MET WITH:Farrah Siddiqui - CaregiverTIME VISIT/
INSPECTION COMPLETED:
03:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced Required- 1 year visit. LPA was
met by Farrah Siddiqui, Caregiver and explained the purpose of the visit. The co-administrator, Maria Bangash was called to inform of the visit. The facility is approved to serve residents age range 60 and above, (6) non ambulatory residents of which (1) may be bedridden. Facility is approved hospice waiver for (3) residents. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:

Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were maintained.
Infection control plan was developed and reviewed/updated on 07/01/2026 by the administrator. Bathroom has hygiene items such as paper towel, hand soap and toilet paper.
Operational Requirements: The facility has a dementia care plan to accept or retain residents with dementia. Staff does not have the complete (12) hours of required training to provide special care to dementia residents. Facility maintains liability insurance in the amount of at least one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate and expires on 09/18/2026.
Physical Plant/Environment Safety: The facility is a 2-story home located in a residential
neighborhood, 1st floor consists of (5) resident bedrooms, (3) bathrooms, (2) living rooms (one has a covered fireplace), (2) dining areas, kitchen, and backyard with a separate storage shed. 2nd floor consists of (4) bedrooms, (1) of which is a staff bedroom with uncovered fireplace, (2) bathrooms, laundry area. There are currently (6) residents, 60 years and older residing in the facility, (2) are under hospice care and (1) bedridden. The interior and exterior physical plant was inspected. Resident bedrooms were toured. Each bedroom has a smoke detector, linen, light, chair and sufficient closet space. Backyard was inspected and there is a locked storage shed to house tools, garden supplies and other miscellaneous items. There is (1) unmounted fire extinguisher purchased on 02/19/2026. LPA observed a partially exposed ceiling in the downstairs hallway due to a water leak. Staff stated that a repairman has already been called and would be back to finish the work today or tomorrow. Knives, cleaning solutions, and disinfectants are locked. Smoke alarms and carbon monoxide were tested and operable. The facility has a video camera monitor system in the common areas. Hot water temperature reading measured within the required 105 - 120 degrees Fahrenheit (110.3 deg F in bathroom downstairs and 117.9 deg F in bathroom upstairs). *****REPORT CONTINUED ON LIC809-C*****
David Sicairos
Bennette Pena
DATE: 07/31/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/31/2026
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 7
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA
FACILITY NAME: DEVONSHIRE ELDERLY CARE
FACILITY NUMBER: 197609500
VISIT DATE: 07/31/2026
NARRATIVE
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Staffing: A total of (4) caregivers including the Administrator provide care and supervision to the residents.
Staff employed are over the age of 18 and have criminal background clearance, fingerprint cleared, have the
required training and associated to the facility.
Personnel Records-Training: Staff files were reviewed for criminal background clearance and training. Only (1) staff record was available during the visit. Staff #1/S1's files have health screening, personnel record and training. Co-administrator has a valid certificate, expires on 03/14/2027.
Resident Rights-Information: Resident personal rights are posted. Facility provides internet services to all
residents and have access to the facility phone.
Planned Activities: The facility provides sufficient space to accommodate both indoor and outdoor activities.
Residents are encouraged to participate in a variety of planned activities.
Food Service: The kitchen was inspected and has sufficient supply of 2 day perishable & 7 day
non-perishable food. There are (2) extra/freezer refrigerators, one in the dining area and one in the 2nd living room.
Incidental Medical Services: Residents' medications were reviewed during the visit. The facility uses the
Medication Administration Record (MAR) log to document medications given. Medications are stored in a
locked cabinet and inaccessible to residents. Staff #1 did not properly document the medications (MAR not initialed) administered to the resident on the medication administration record (MAR).
Resident Records-Incident Reports: Resident files were reviewed containing admission agreements, Physician's Report, Medical/Functional assessments, Needs and Services Plans, Personal rights, Medical Consent, Medication Records.
Disaster Preparedness: The facility has a complete Emergency Disaster and Mass Casualty Plan containing
emergency evacuation, storage and preservation of medications, operation of manual assist devices. Last fire drill was conductedon 07/03/2026.
Residents with SHN: (1) resident is bedridden and (2) residents are under hospice care, no one is currently using oxygen.

Deficiencies cited and Technical advisories issued. Exit interview was conducted with the co-administrator, Maria Bangash on the phone and a copy of this report along with the appeal rights were provided to Farrah Siddiqui, Caregiver.
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Bennette Pena
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/31/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/31/2026
LIC809 (FAS) - (06/04)
Page: 3 of 7
Document Has Been Signed on 07/31/2026 03:19 PM - It Cannot Be Edited


Created By: Bennette Pena On 07/31/2026 at 02:40 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
,
, CA

FACILITY NAME: DEVONSHIRE ELDERLY CARE
FACILITY NUMBER: 197609500

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/31/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(d)(3)
Incidental Medical and Dental Care Services
(d) If the resident is unable to determine his/her own need for a prescription or nonprescription PRN medication, and is unable to communicate his/her symptoms clearly, facility staff designated by the licensee, shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (3) The date and time the PRN medication was taken, the dosage taken, and the resident's response shall be documented and maintained in the resident's facility record.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in that the medication administration records (MARs) for the residents were not properly documented. The morning and afternoon medications for (2) residents were administered by S1 for 07/31/2026, but the record was not initialed which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/03/2026
Plan of Correction
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Administrator to ensure that the administered medications to all the residents shall be properly documented in the Medication Administration Record (MAR). Administrator to re-train staff regarding proper documentation and send an in service training log to LPA/CCLD by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
David Sicairos
NAME OF LICENSING PROGRAM MANAGER:
Bennette Pena
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/31/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/31/2026


LIC809 (FAS) - (06/04)
Page: 4 of 7
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)
Page: 2 of 7
Document Has Been Signed on 07/31/2026 03:19 PM - It Cannot Be Edited


Created By: Bennette Pena On 07/31/2026 at 02:40 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
,
, CA

FACILITY NAME: DEVONSHIRE ELDERLY CARE
FACILITY NUMBER: 197609500

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/31/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.626(a)(1)
Other Provisions
(a) All residential care facilities for the elderly shall meet the following training requirements, as described in Section 1569.625, for all direct care staff: (1) Twelve hours of dementia care training, six of which shall be completed before a staff member begins working independently with residents, and the remaining six hours of which shall be completed within the first four weeks of employment. All 12 hours shall be devoted to the care of persons with dementia. The facility may utilize various methods of instruction, including, but not limited to, preceptorship, mentoring, and other forms of observation and demonstration. The orientation time shall be exclusive of any administrative instruction.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on (interview) (record review), the licensee did not comply with the section cited above in that Staff #1 completed (6) hours of dementia training on 02/21/2025, however there was no proof of training for the remaining (6) hours of which shall be completed within (4) weeks of employment which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/12/2026
Plan of Correction
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Administrator to ensure that staff have the required training and send a copy of the remaining (6) hours of dementia training certificate to LPA/CCLD by 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.
David Sicairos
NAME OF LICENSING PROGRAM MANAGER:
Bennette Pena
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/31/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/31/2026


LIC809 (FAS) - (06/04)
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