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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609782
Report Date: 06/16/2026
Date Signed: 06/16/2026 05:23:45 PM

Document Has Been Signed on 06/16/2026 05:23 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:CARRIES CARE VILLAFACILITY NUMBER:
197609782
ADMINISTRATOR/
DIRECTOR:		ACOSTA, MARK RYANFACILITY TYPE:
740
ADDRESS:12550 BURTON STTELEPHONE:
(818) 767-4503
CITY:NORTH HOLLYWOODSTATE: CAZIP CODE:
91605
CAPACITY: 6CENSUS: 5DATE:
06/16/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:33 AM
MET WITH:Carrie AcostaTIME VISIT/
INSPECTION COMPLETED:
05:30 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) Trevor Byrne arrived at the facility unannounced to conduct a required annual visit at 09:33 AM. LPA met with Licensee Representative Carrie Acosta. Entrance interview conducted and the reason for the visit was explained.

Beginning at 09:35 AM the LPA, along with the Licensee Representative 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:

KITCHEN: The LPA observed the kitchen area to be relatively clean. Kitchen appliances appeared to be in operable condition. The facility had a sufficient supply of two (2) days perishable and seven (7) days non-perishable food. LPA observed a secured under-sink cabinet which contained cleaning chemicals. LPA observed a secured drawer which contained knives and other sharp objects. LPA observed an unlocked cabinet which contained medication bottles. LPA notified the Licensee Representative who immediately secured the items. Located adjacent to the kitchen is the facility’s washer and dryer room. LPA observed this room to contain the facility’s washer/dryer, dry food storage, and a fire extinguisher that was last serviced on 06/29/2025. LPA observed six (6) cans of expired food stored in this room. LPA notified the Administrator who agreed to conduct an audit of all of the facility’s food supplies and to dispose of any additional expired food items.

CONTINUED ON LIC 809C.

NAME OF LICENSING PROGRAM MANAGER: Kasandra Lopez
NAME OF LICENSING PROGRAM ANALYST: Trevor Byrne
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 06/16/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/16/2026
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 20
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 20
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: CARRIES CARE VILLA
FACILITY NUMBER: 197609782
VISIT DATE: 06/16/2026
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: This includes the living room, hallway, and dining area. LPA observed the living room to be clean and properly furnished at the time of the visit. The living room contained a television and activities for resident use. Additionally, the living room contained a fire extinguisher that was last serviced on 06/29/2025. The dining area was observed to be equipped with adequate seating for resident use. Additionally, the dining room contained a locked storage cabinet which contained resident medications. The facility’s fire and carbon monoxide alarms were tested at 01:45 PM and were functional at the time of the visit. LPA observed cameras located throughout the common areas of the facility and confirmed with the Licensee Representative that audio is not recorded. All exits to the outdoors of the facility were observed to have functioning auditory alarms.

BEDROOMS: There are four (4) bedrooms in the facility; three (3) are dual occupancy resident rooms and one (1) is a staff room. LPA and the Licensee Representative toured all four (4) bedrooms. All resident rooms were observed to be furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting. LPA observed the staff bedroom to be unlocked. LPA observed the staff bedroom to contain unsecured grooming supplies. LPA observed the emergency exit in bedroom # 3 to be blocked from opening by a metal bar. LPA informed the Licensee Representative who removed the bar at the time of the visit.

BATHROOMS: There are two (2) bathrooms at the facility. One (1) is designated as a shared/common resident bathroom and one (1) is a staff bathroom. The resident bathroom was observed to be relatively clean and was equipped with nonskid surfaces. Grab bars were observed in the resident shower and near the resident toilet and all were properly secured. The water temperature was measured to be 127.6 degrees Fahrenheit, which is outside of the range required by regulation.

OUTDOOR SPACE: The facility has one (1) emergency exit gate located in the front yard of the facility; LPA observed clear passageways for emergency exit use. The facility has adequate shaded seating outdoors for resident use. LPA observed the garage and ADU on the property. The ADU was observed to be appropriately secured. LPA observed the garage to contain the facility’s emergency food and water supply. LPA observed expired food items located in the garage. Additionally, LPA observed chemicals to be stored in the same area as the emergency food supplies. LPA informed the Licensee Representative that toxic substances shall not be stored in food storerooms. The Licensee Representative expressed understanding and agreed to remove the chemicals from the food storage area.

Continued on LIC 809C.

NAME OF LICENSING PROGRAM MANAGER: Kasandra Lopez
NAME OF LICENSING PROGRAM ANALYST: Trevor Byrne
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/16/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2026
LIC809 (FAS) - (06/04)
Page: 3 of 20
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: CARRIES CARE VILLA
FACILITY NUMBER: 197609782
VISIT DATE: 06/16/2026
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
RECORD REVIEW: Record review began at 10:39 AM. Staff and resident records were reviewed for documents including, but not limited to: health screening, TB test, staff training records, fingerprint clearance, resident physician's report, needs and service appraisal, consent forms, and personal rights. Three (3) staff files were reviewed. One (1) staff file was observed to be missing a health screening, proof of a negative Tuberculosis (TB) test, and a signed criminal record statement. LPA notified the Licensee Representative who agreed to obtain the missing files for the identified employee. LPA observed the training records for two (2) employees to be missing the dates that they received the trainings. LPA notified the Licensee Representative who agreed to submit a true and accurate training record for the identified employees to Community Care Licensing Division (CCLD). Five (5) resident files were reviewed. Two (2) resident files were observed to be missing proof of a negative TB test. Two (2) resident medical assessments were observed to be missing the ambulatory status of the residents. Four (4) resident files were observed to be missing a resident personal property inventory record. LPA notified the Licensee Representative who agreed to obtain the missing documentation. LPA informed the Licensee Representative that they were recently cited for a violation of Health and Safety Code (HSC) 1569.153(d) on 06/27/2025. LPA informed the Licensee Representative that because they violated the same licensing regulation within a twelve (12) month period a civil penalty in the amount of $250 is being assessed on today’s date (06/16/2026).

MEDICATION REVIEW: Medication review began at 01:04 PM. Medications for three (3) of five (5) residents were observed. All medications were stored properly and were appropriately documented on their respective centrally stored medication and destruction record sheets.

INFECTION CONTROL/EMERGENCY DISASTER PLANNING: During today’s visit, the LPA reviewed the facility's infection control practices and the facility's emergency disaster plan. The facility’s policies and procedures as they pertain to infection control are adequate. Emergency disaster drills are conducted quarterly; and the last disaster drill was conducted on 06/15/2026. The facility’s emergency disaster plan is up to date and is adequate. Both the infection control plan and the emergency disaster plan are reviewed/updated annually by the facility’s Licensee Representative.

INTERVIEWS: LPA interviewed five (5) residents. Residents interviewed expressed concerns with the facility. LPA interviewed one (1) staff members . The staff members interviewed was knowledgeable on their roles and responsibilities, the resident’s rights, the forms of abuse, and the appropriate reporting procedures for suspected abuse. CONTINUED ON LIC 809C.

NAME OF LICENSING PROGRAM MANAGER: Kasandra Lopez
NAME OF LICENSING PROGRAM ANALYST: Trevor Byrne
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/16/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2026
LIC809 (FAS) - (06/04)
Page: 4 of 20
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: CARRIES CARE VILLA
FACILITY NUMBER: 197609782
VISIT DATE: 06/16/2026
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 LPA obtained copies of the facility’s emergency disaster plan, LIC 500, resident roster, and current liability insurance.

Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited and civil penalty assessed (refer to LIC 809-D): Exit interview conducted and copy of the report was issued and appeal rights provided.

NAME OF LICENSING PROGRAM MANAGER: Kasandra Lopez
NAME OF LICENSING PROGRAM ANALYST: Trevor Byrne
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/16/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2026
LIC809 (FAS) - (06/04)
Page: 5 of 20
Document Has Been Signed on 06/16/2026 05:23 PM - It Cannot Be Edited


Created By: Trevor Byrne On 06/16/2026 at 03:38 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
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: CARRIES CARE VILLA
FACILITY NUMBER: 197609782

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/16/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

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 the facility's hot water temperature was measured to be 127.6 degrees F which poses an immediate health risk to persons in care.
POC Due Date: 06/17/2026
Plan of Correction
1
2
3
4
Licensee Representative agreed to provide proof of an appropriate water temperature measured at the resident faucet to CCLD no later than POC due date.
Type A
Section Cited
CCR
87309(a)(1)
Storage Space and Access
(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage. (1) Disinfectants, cleaning solutions, and poisonous substances shall be stored in areas separate from food supplies as specified in Section 87555, General Food Service Requirements.

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 cleaning chemicals, detergents, and other toxic items were stored in the same storage area of the garage as the facility's emergency food supply which poses an immediate health risk to persons in care.
POC Due Date: 06/17/2026
Plan of Correction
1
2
3
4
Licensee Representative agreed to remove the identified items from the food storage area and to relocate the items to appropriate locked storage. Licensee Representative agreed to send proof of the removed items 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 Lopez
NAME OF LICENSING PROGRAM MANAGER:
Trevor Byrne
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/16/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/16/2026


LIC809 (FAS) - (06/04)
Page: 6 of 20
Document Has Been Signed on 06/16/2026 05:23 PM - It Cannot Be Edited


Created By: Trevor Byrne On 06/16/2026 at 03:38 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
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: CARRIES CARE VILLA
FACILITY NUMBER: 197609782

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/16/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(f)
Storage Space and Access
(f) Due to the physical arrangements in the facility, or the condition or the habits of other residents in the facility, or both, the licensee may require the items specified in subsections (a) and (c) to be centrally stored so as not to pose a safety hazard to others.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and record review, the licensee did not comply with the section cited above as personal grooming supplies were left unsecured in the staff bedroom when one resident was determined by their physician to be at risk if allowed access to those items which poses an immediate health risk to persons in care.
POC Due Date: 06/16/2026
Plan of Correction
1
2
3
4
Licensee Representative secured the items at the time of the visit. POC cleared.
Type A
Section Cited
CCR
87465(h)(2)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

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 multiple medications belonging to the Administrator and a former resident were left in an unsecured cabinet in the kitchen which posed an immediate health risk to persons in care.
POC Due Date: 06/16/2026
Plan of Correction
1
2
3
4
Licensee Representative secured the items at the time of the visit. POC cleared.
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 Lopez
NAME OF LICENSING PROGRAM MANAGER:
Trevor Byrne
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/16/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/16/2026


LIC809 (FAS) - (06/04)
Page: 7 of 20
Document Has Been Signed on 06/16/2026 05:23 PM - It Cannot Be Edited


Created By: Trevor Byrne On 06/16/2026 at 03:38 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
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: CARRIES CARE VILLA
FACILITY NUMBER: 197609782

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/16/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87307(d)(4)
Personal Accommodations and Services
(4) Stairways, inclines, ramps and open porches and areas of potential hazard to residents with poor balance or eyesight shall be made inaccessible to residents unless equipped with sturdy hand railings and unless well-lighted.

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 the railings attached to the emergency exit ramp and outdoor kitchen stairway were not properly secured which poses a potential safety risk to persons in care.
POC Due Date: 06/30/2026
Plan of Correction
1
2
3
4
Licensee Representative agreed to submit proof of appropriately secured railings to CCLD no later than POC due date.
Type B
Section Cited
CCR
87307(d)(6)
Personal Accommodations and Services
(6) All outdoor and indoor passageways and stairways shall be kept free of obstruction.

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 the emergency exit in bedroom # 3 was blocked from opening by a metal bar which posed a potential safety risk to persons in care.
POC Due Date: 06/30/2026
Plan of Correction
1
2
3
4
Licensee Representative agreed to submit a statement of understanding confirming that they will not block any exits in the facility, Licensee Representative agreed to submit the statement 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 Lopez
NAME OF LICENSING PROGRAM MANAGER:
Trevor Byrne
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/16/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/16/2026


LIC809 (FAS) - (06/04)
Page: 8 of 20
Document Has Been Signed on 06/16/2026 05:23 PM - It Cannot Be Edited


Created By: Trevor Byrne On 06/16/2026 at 03:38 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
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: CARRIES CARE VILLA
FACILITY NUMBER: 197609782

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/16/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(c)(2)(C)
Personnel Records
(c) Licensees shall maintain in the personnel records verification of required staff training and orientation. (2) Documentation of staff training shall include: (C) Date(s) of attendance; and

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 staff trainings were missing the dates of attendance for the trainings which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/30/2026
Plan of Correction
1
2
3
4
The Licensee Representative agreed to submit a true and accurate training record for the identified employees to CCLD no later than POC due date.
Type B
Section Cited
CCR
87219(a)
Planned Activities
(a) Residents shall be encouraged to maintain and develop their quality of life through participation in a variety of planned activities. The activities made available shall include:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on interviews, the licensee did not comply with the section cited above as interviews revealed that no activities are offered at the facility for residents to participate in which poses a potential personal rights risk to persons in care.
POC Due Date: 06/30/2026
Plan of Correction
1
2
3
4
The Licensee Representative agreed to submit their plan on how they will ensure adequate activities are offered to residents at the facility. The Licensee Representative agreed to submit their plan 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 Lopez
NAME OF LICENSING PROGRAM MANAGER:
Trevor Byrne
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/16/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/16/2026


LIC809 (FAS) - (06/04)
Page: 9 of 20
Document Has Been Signed on 06/16/2026 05:23 PM - It Cannot Be Edited


Created By: Trevor Byrne On 06/16/2026 at 03:38 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
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: CARRIES CARE VILLA
FACILITY NUMBER: 197609782

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/16/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87555(a)
General Food Service Requirements
(a) The total daily diet shall be of the quality and in the quantity necessary to meet the needs of the residents an shall meet the Recommended Dietary Allowances of the Food and Nutrition Board of the National Research Council. All food shall be selected, stored, prepared and served in a safe and healthful manner.

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 the facility retained expired food items in the dry food storage and emergency food storage which poses a potential health risk to persons in care.
POC Due Date: 06/30/2026
Plan of Correction
1
2
3
4
The Licensee Representative agreed to conduct an audit of all food items stored at the facility and to dispose of any expired food items. The Licensee Representative agreed to submit proof of the completed audit to CCLD no later than POC due date.
Type B
Section Cited
CCR
87458(c)(1)(A)
Medical Assessment
(c) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the licensed medical professional's diagnosis or diagnoses and results of an examination for all of the following: (A) Communicable tuberculosis.

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 two residents were observed to be missing proof of a negative TB test in their file which poses a potential health risk to persons in care.
POC Due Date: 06/30/2026
Plan of Correction
1
2
3
4
Licensee Representative agreed to obtain proof of a negative TB test for the identified individuals and to send proof of the negative TB test 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 Lopez
NAME OF LICENSING PROGRAM MANAGER:
Trevor Byrne
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/16/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/16/2026


LIC809 (FAS) - (06/04)
Page: 10 of 20
Document Has Been Signed on 06/16/2026 05:23 PM - It Cannot Be Edited


Created By: Trevor Byrne On 06/16/2026 at 03:38 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
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: CARRIES CARE VILLA
FACILITY NUMBER: 197609782

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/16/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87458(c)(5)
Medical Assessment
(c) The medical assessment shall include, but not be limited to: (5) The determination whether the person is ambulatory or nonambulatory as defined in Section 87101, Definitions, or bedridden as defined in Health and Safety Code section 1569.72. The assessment shall indicate whether nonambulatory status is based upon the resident's physical condition, mental condition, or both.

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 a resident's medical assessment was missing their ambulator status which poses a potential health risk to persons in care.
POC Due Date: 06/30/2026
Plan of Correction
1
2
3
4
Licensee Representative agreed to obtain a medical assessment that accurately reflects the resident's ambulatory status and to send the updated medical assessment to CCLD no later than POC due date.
Type B
Section Cited
CCR
87355(d)
87355 Criminal Record Clearance
(d) All individuals subject to criminal record review shall be fingerprinted and sign a Criminal Record Statement (LIC 508 [Rev. 1/03]) under penalty of perjury.

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 employee did not have a signed LIC 508 in their file which poses a potential safety risk to persons in care.
POC Due Date: 06/30/2026
Plan of Correction
1
2
3
4
Administrator agreed to obtain a signed LIC 508 for the identified staff member and to send proof of the signed statement 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 Lopez
NAME OF LICENSING PROGRAM MANAGER:
Trevor Byrne
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/16/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/16/2026


LIC809 (FAS) - (06/04)
Page: 11 of 20
Document Has Been Signed on 06/16/2026 05:23 PM - It Cannot Be Edited


Created By: Trevor Byrne On 06/16/2026 at 04:19 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
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: CARRIES CARE VILLA
FACILITY NUMBER: 197609782

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/16/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.153(d)
§1569.153 Theft and loss program; standards, property inventories and surrender of personal effects; secured areas
(d) A written resident personal property inventory is established upon admission and retained during the resident's stay in the residential care facility for the elderly. Inventories shall be written in ink, witnessed by the facility and the resident or resident's representative, and dated. A copy of the written inventory shall be provided to the resident or the person acting on the resident's behalf. All additions to an inventory shall be made in ink, and shall be witnessed by the facility and the resident or resident's representative, and dated. Subsequent items brought into or removed from the facility shall be added to or deleted from the personal property inventory by the facility at the written request of the resident, the resident's family, a responsible party, or a person acting on behalf of a resident. The facility shall not be liable for items which have not been requested to be included in the inventory or for items which have been deleted from the inventory. A copy of a current inventory shall be made available upon request to the resident, responsible party, or other authorized representative. The resident, resident's family, or a responsible party may list those items which are not subject to addition or deletion from the inventory, such as personal clothing or laundry, which are subject to frequent removal from the facility.


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 4 resident files were observed to be missing completed records of property/valuables which poses a potential personal rights risk to persons in care.
POC Due Date: 06/30/2026
Plan of Correction
1
2
3
4
Licensee Representative agreed to complete a record of property/valuables for the identified residents and to send proof of the completed records 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 Lopez
NAME OF LICENSING PROGRAM MANAGER:
Trevor Byrne
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/16/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/16/2026


LIC809 (FAS) - (06/04)
Page: 20 of 20