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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609670
Report Date: 06/17/2025
Date Signed: 06/17/2025 03:43:58 PM

Document Has Been Signed on 06/17/2025 03:43 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:FAIR OAKS MANORFACILITY NUMBER:
197609670
ADMINISTRATOR/
DIRECTOR:		BONZON, TEDFACILITY TYPE:
735
ADDRESS:5035 ECHO STTELEPHONE:
(818) 846-4469
CITY:LOS ANGELESSTATE: CAZIP CODE:
90042
CAPACITY: 32CENSUS: 29DATE:
06/17/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Assisrtant Adminstrator, Michael Bacolcol and Administrator, Mohammad BaigTIME VISIT/
INSPECTION COMPLETED:
03:55 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
At 9:30a.m., Licensing Program Analyst (LPA) Antonia Alvizar-Ettima conducted an annual required visit and inspection of the facility. LPA met with Assistant Administrator and contacted the Administrator via-phone and LPA discussed the purpose of this visit. Later Administrator joined todays visit.

At about 10:00a.m. LPA and Assistant Administrator conducted a physical plant tour inside and out. During the tour, LPA observed that the facility is a two story house located in a residential community. Required postings were observed in the entry area. The smoke alarms are operational that are located in each bedroom, the hallway and kitchen. There are carbon monoxide detectors that functions properly. The fire extinguishers are in the kitchen, hallways and throughout the facility. The charge date is 05/05/2025. Emergency Disaster Drill was last conducted on 03/24/2025. The facility is fire cleared for thirty-two (32) ambulatory residents.

LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:

Kitchen: The kitchen appliances and fixtures were functional. The kitchen has a working gas stove, faucet, freezer, refrigerator, and microwave. LPA found at least two (2) days perishable and seven (7) days non-perishable food at the facility that is properly stored. Frozen foods are wrap, dated, and stored properly as well. Knives were stored in a locked cabinet in the kitchen. The menu was posted for review (ARF), snacks and beverages are available for the client in the facility when they want. Food storage and preparation areas are clean and inaccessible to pests. Cleaning supplies, pesticides or toxic cleaning supplies were stored and locked in storage room in the hallway. Bedrooms: There were seventeen (17)

Continue to LIC 809-C

NAME OF LICENSING PROGRAM MANAGER: Naira Margaryan
NAME OF LICENSING PROGRAM ANALYST: Antonia Alvizar-Ettima
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 06/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/17/2025
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 3
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 3
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: FAIR OAKS MANOR
FACILITY NUMBER: 197609670
VISIT DATE: 06/17/2025
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
bedrooms designated for clients' use. All bedrooms are shared. Bedrooms were toured and observed to properly furnished with appropriate dresser, beddings, and linens with sufficient lighting. There was enough clean linen available in the cabinets in the hallway and the laundry room. Bathrooms: There are five (5) bathrooms designated for clients' use. The bathrooms were properly supplied and had functional fixtures. Hot water temperature measured at a range of 115.9°F to 118.9°F and within the required range. Client’s personal hygiene supplied are kept in their room. Towels and washcloths are not shared. Common Areas: LPA toured all common areas of the facility. These included the living room and dining area for clients. The common areas were properly furnished. Clients have a dining area beside the kitchen. LPA observed common areas to be very clean and tidy. There are no issues with Fire Clearance. Surrounding Grounds: Entry and exits were free of obstruction. There was furniture appropriate for outdoor use. The facility does not have body of water. The facility has a detached garage that is used as storage for cleaning supplies, extra personal hygiene, diapers, and other items. The facility has a back parking area. Laundry Service: LPA observed two (2) working washers and two (2) dryers in the laundry rooms. Above a washer and dryer there are locked cabinets storing laundry clean linens. There is enough linen available to change weekly or more if need. Detergents, cleaning agents and other toxins were properly stored and locked in storage room in the hallway. Medications: are in a centrally stored and locked place, including over-the-counter medicines; medications are properly labeled and checked for expiration dates. Each centrally stored prescription and PRN medication has been logged in the medications log with proper documentation from the clients’ doctor. Proper medication dispensing instruction are followed and checked for contamination. First-aid has all proper items and is current. Client Records: LPA conducted a client record review for five (5) out of twenty-nine (29) clients for requirements and eligibility. LPA also reviewed surety bonds (LIC 402) a copy was handed to LPA. Planned activities are offered. Staff Files: LPA conducted a file review of staff records to ensure forms and training are up to date and compliance with licensing forms. Records were checked for criminal record clearances and current First Aid. The administrator file was reviewed for fingerprint clearance, administrator certificate, and current First Aid. The office space is beside the entrance.

Facility is within CA code of Regulations Title 22 or Health and Safety Code. No deficiencies were found, exit interview conducted, copy of report was provided.

NAME OF LICENSING PROGRAM MANAGER: Naira Margaryan
NAME OF LICENSING PROGRAM ANALYST: Antonia Alvizar-Ettima
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2025
LIC809 (FAS) - (06/04)
Page: 3 of 3