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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609782
Report Date: 06/27/2025
Date Signed: 06/27/2025 04:45:02 PM

Document Has Been Signed on 06/27/2025 04:45 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: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 6DATE:
06/27/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:45 AM
MET WITH:Carrie AcostaTIME VISIT/
INSPECTION COMPLETED:
04:45 PM
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Licensing Program Analyst (LPA) Trevor Byrne arrived at the facility unannounced to conduct a required annual visit at 09:45 AM. LPA met with facility staff who contacted the Licensee Representative Carrie Acosta. The Licensee Representative arrived to the facility at 10:13 AM. Entrance interview conducted and the reason for the visit was explained.

Beginning at 10:15 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:

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 contains a television and activities for resident use. Additionally, the living room contained a fire extinguisher that contained a tag stating the last service was conducted on 06/29/2025. LPA interviewed the Licensee Representative and asked why the tag was stamped for two (2) days from the date of today’s inspection (06/27/2025). The Licensee Representative stated that the fire extinguishers were serviced yesterday (06/26/2025) and were unsure why the person servicing them stamped the incorrect date. The dining area was observed to be equipped with adequate seating for resident use. Additionally, the dining room contained an extra refrigerator and a storage cabinet which contained resident medication. LPA observed a closet in the hallway to contain extra linens. All furniture throughout the facility was observed to be clean and in good repair. The facility’s combination fire and carbon monoxide alarms were tested at 01:13 PM and were functional at the time of the visit. All exits in the facility were observed to contain functioning auditory alarms. LPA observed cameras located throughout the common areas of the facility and confirmed with the Licensee Representative that audio is not recorded.
Continued on LIC 809C.
Kasandra LopezTELEPHONE: (818) 596-4343
Trevor ByrneTELEPHONE: 747-444-6104
DATE: 06/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/27/2025
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: CARRIES CARE VILLA
FACILITY NUMBER: 197609782
VISIT DATE: 06/27/2025
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KITCHEN: The LPA observed the kitchen area to be clean. Kitchen appliances appeared to be in operable condition. The facility has a sufficient supply of two (2) days perishable and seven (7) days non-perishable food. LPA observed a secured under-sink cabinet to contain cleaning chemicals and a secured drawer to contain knives and other sharp objects. Adjacent to the kitchen was the facility’s washer and dryer closet. LPA observed secured storage containing laundry chemicals.

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. Bedrooms #3 and 4 were observed to have narrow passageways due to furniture/clutter which would make it difficult for residents using a wheelchair or walker to traverse the room. Licensee Representative agreed to rearrange the rooms and remove clutter to allow for easy passage by residents.

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. The resident bathroom contained a toilet that was observed to contain a large piece of the ceramic broken off and missing on the water tank. Additionally, LPA observed an unsecured under-sink storage to contain cleaning chemicals. LPA informed the Licensee Representative of the deficiencies, the Licensee Representative agreed to replace the broken toilet and secured the chemicals at the time of the visit. Grab bars were observed in the resident shower and near the resident toilet. The water temperature was measured to be 115 degrees Fahrenheit, which is within 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 a secured storage shed that contained miscellaneous care supplies and household items. LPA observed the garage and ADU on the property. The ADU was observed to be appropriately secured. LPA observed the garage to contain an additional refrigerator and the facility’s emergency food and water supply. LPA observed expired food items located in the garage. LPA informed the Licensee Representative who agreed to conduct an audit of the food items and remove any expired items from the storage.
Continued on LIC 809C.
SUPERVISOR'S NAME: Kasandra LopezTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Trevor ByrneTELEPHONE: 747-444-6104
LICENSING EVALUATOR SIGNATURE:

DATE: 06/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/27/2025
LIC809 (FAS) - (06/04)
Page: 3 of 13
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: 06/27/2025
NARRATIVE
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RECORD REVIEW: Record review began at 11:35 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. Two (2) staff files were reviewed. All staff files contained all required documentation. LPA did not observe staff training records located in the staff files. LPA interviewed the Licensee Representative who stated that the staff had started recently and had received approximately eight (8) hours of training. LPA informed Licensee Representative that staff are required to have a minimum of twenty (20) hours of training before providing assistance to residents. Licensee Representative agreed to conduct the additional training with staff. six (6) resident files were reviewed. One (1) resident file was observed to contain a physician’s report that did not contain accurate information on the resident’s current condition. LPA informed the Licensee Representative who confirmed that this is the most recent physician’s report they had on file. LPA informed the Licensee Representative that an updated Physicians report must be obtained following a change in condition of a resident. Licensee Representative agreed to obtain an updated physicians report for the identified resident. Additionally, LPA observed six (6) resident files to have incomplete and unsigned personal property inventory records. LPA informed Licensee Representative who agreed to complete the forms with each resident. LPA observed three (3) resident files to be missing signed copies of the personal rights of residents. LPA informed the licensee representative who agreed to obtain signed copies of the form for the identified residents.

MEDICATION REVIEW: Medication review began at 01:04 PM. Medications for two (2) of six (6) residents were observed. All medications were stored properly and were appropriately documented on their respective centrally stored medication and destruction record sheets. No deficiencies were observed during medication review.

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 it pertains to infection control are adequate. Emergency disaster drills are to be conducted quarterly; the Licensee Representative was unable to provide LPA with the last date of the facility’s completed emergency disaster drill. 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. Continued on LIC 809C.
SUPERVISOR'S NAME: Kasandra LopezTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Trevor ByrneTELEPHONE: 747-444-6104
LICENSING EVALUATOR SIGNATURE:

DATE: 06/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/27/2025
LIC809 (FAS) - (06/04)
Page: 4 of 13
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: 06/27/2025
NARRATIVE
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INTERVIEWS: LPA interviewed three (3) residents. Two (2) residents interviewed stated that the staff treat them well and are attentive to their needs. LPA interviewed two (2) staff members with the assistance of telephonic translation services. The staff members interviewed were knowledgeable on their roles and responsibilities, the resident’s rights, the forms of abuse, and the appropriate reporting procedures for suspected abuse.

During today’s visit the Licensee Representative agreed to email LPA a copy of the facility’s LIC 500, resident roster, and current 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: 06/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/27/2025
LIC809 (FAS) - (06/04)
Page: 5 of 13
Document Has Been Signed on 06/27/2025 04:45 PM - It Cannot Be Edited


Created By: Trevor Byrne On 06/27/2025 at 03:19 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: 06/27/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
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.

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 an under-sink storage in the resident bathroom contained cleaning chemicals and was unlocked which poses an immediate health and safety risk to persons in care.
POC Due Date: 06/27/2025
Plan of Correction
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Licensee Representative secured the chemicals at the time of the visit. POC cleared.
Section Cited
Deficient Practice Statement
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3
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POC Due Date:
Plan of Correction
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4
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:
TELEPHONE: (818) 596-4343
Trevor Byrne
NAME OF LICENSING PROGRAM ANALYST:
TELEPHONE: 747-444-6104
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/27/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/27/2025


LIC809 (FAS) - (06/04)
Page: 6 of 13
Document Has Been Signed on 06/27/2025 04:45 PM - It Cannot Be Edited


Created By: Trevor Byrne On 06/27/2025 at 03:19 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: 06/27/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.153(d)
Licensing
(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 six residents had incomplete personal property inventory records which poses a potential personal rights risk to persons in care.
POC Due Date: 07/11/2025
Plan of Correction
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Licensee Representative agreed to complete the personal property records for the six identified residents 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:
TELEPHONE: (818) 596-4343
Trevor Byrne
NAME OF LICENSING PROGRAM ANALYST:
TELEPHONE: 747-444-6104
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/27/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/27/2025


LIC809 (FAS) - (06/04)
Page: 7 of 13
Document Has Been Signed on 06/27/2025 04:45 PM - It Cannot Be Edited


Created By: Trevor Byrne On 06/27/2025 at 03:19 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: 06/27/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

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 resident bathroom toilet was observed to be missing a large portion of the ceramic on the water tank leaving a sharp edge exposed which poses a potential health and safety risk to persons in care.
POC Due Date: 07/11/2025
Plan of Correction
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Licensee Representative agreed to replace the toilet no later than POC due date.
Type B
Section Cited
CCR
87307(a)(2)(A)
87307 Personal Accommodations and Services
(a) Living accommodations and grounds shall be related to the facility's function. The facility shall be large enough to provide comfortable living accommodations and privacy for the residents, staff, and others who may reside in the facility. The following provisions shall apply:
(2) Resident bedrooms shall be provided which meet, at a minimum, the following requirements:
(A) Bedrooms shall be large enough to allow for easy passage between and comfortable usage of beds and other required items of furniture specified below, and any resident assistant devices such as wheelchairs or walkers.
This requirement is not met as evidenced by:
Deficient Practice Statement
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3
4
Based on observation, the licensee did not comply with the section cited above as two bedrooms had furniture and personal items cluttering the area where residents would traverse which poses/posed a potential safety or personal rights risk to persons in care.
POC Due Date: 07/11/2025
Plan of Correction
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2
3
4
Licensee representative agreed to rearrange the rooms and remove personal clutter to allow for easy passage of residents 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:
TELEPHONE: (818) 596-4343
Trevor Byrne
NAME OF LICENSING PROGRAM ANALYST:
TELEPHONE: 747-444-6104
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/27/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/27/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/27/2025 04:45 PM - It Cannot Be Edited


Created By: Trevor Byrne On 06/27/2025 at 03:19 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: 06/27/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.625(b)(1)
Other Provisions
(1) The department shall adopt regulations to require staff members of residential care facilities for the elderly who assist residents with personal activities of daily living to receive appropriate training. This training shall consist of 40 hours of training. A staff member shall complete 20 hours, including six hours specific to dementia care, as required by subdivision (a) of Section 1569.626 and four hours specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696, before working independently with residents. The remaining 20 hours shall include six hours specific to dementia care and shall be completed within the first four weeks of employment. The training coursework may utilize various methods of instruction, including, but not limited to, lectures, instructional videos, and interactive online courses. The additional 16 hours shall be hands-on training.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on interview and record review, the licensee did not comply with the section cited above as two staff members who were providing assistance to residents without the supervision of the Administrator or Licensee Representative did not have a minimum of 20 hours of training prior to providing assistance which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/11/2025
Plan of Correction
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2
3
4
Licensee Representative agreed to conduct the initial 20 hours of training for the identified staff 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:
TELEPHONE: (818) 596-4343
Trevor Byrne
NAME OF LICENSING PROGRAM ANALYST:
TELEPHONE: 747-444-6104
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/27/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/27/2025


LIC809 (FAS) - (06/04)
Page: 9 of 13
Document Has Been Signed on 06/27/2025 04:45 PM - It Cannot Be Edited


Created By: Trevor Byrne On 06/27/2025 at 03:19 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: 06/27/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87468(b)(1)(A)
Personal Rights of Residents
(b) At the time the admission agreement is signed, a resident and the resident's representative shall be personally advised of and given a copy of: (1) The personal rights of residents specified in Sections 87468.1, Personal Rights of Residents in All Facilities and 87468.2, Additional Personal Rights of Residents in Privately Operated Facilities, as applicable to the facility. (A) The licensee shall have each resident and the resident's representative sign a copy of these rights, and the signed copy shall be included in the resident's record.

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 three resident files were missing signed copies of The personal rights of residents which poses a potential personal rights risk to persons in care.
POC Due Date: 07/11/2025
Plan of Correction
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2
3
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Licensee representative agreed to complete the forms for the identified residents no later than POC due date.
Type B
Section Cited
CCR
87555(b)(8)
General Food Service Requirements
(b) The following food service requirements shall apply: (8) All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained.

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 garage was observed to contain expired food items in the emergency food storage which poses a potential health risk to persons in care.
POC Due Date: 07/11/2025
Plan of Correction
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Licensee representative agreed to conduct an audit of all stored food items and to remove any expired food items from storage 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:
TELEPHONE: (818) 596-4343
Trevor Byrne
NAME OF LICENSING PROGRAM ANALYST:
TELEPHONE: 747-444-6104
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/27/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/27/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/27/2025 04:45 PM - It Cannot Be Edited


Created By: Trevor Byrne On 06/27/2025 at 03:19 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: 06/27/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87463(e)
Reappraisals
(e) The licensee shall immediately, or as soon as reasonably possible, bring any significant change in condition, as defined in Section 87101, Definitions, to the attention of the appropriate licensed medical professional and if applicable, other specialized care provider. Documentation of such communication shall be added to the resident's record and shall include:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above as one resident had a significant change in condition that was not reflected on their most up-to-date physicians report which poses a potential health to persons in care.
POC Due Date: 07/11/2025
Plan of Correction
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Licensee representative agreed to obtain an updated medical assessment for the identified resident no later than POC due date.
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above as the facility did not have record of the last completed emergency disaster drill which poses a potential safety risk to persons in care.
POC Due Date: 07/11/2025
Plan of Correction
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Licensee agreed to conduct an emergency disaster drill and send documentation 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:
TELEPHONE: (818) 596-4343
Trevor Byrne
NAME OF LICENSING PROGRAM ANALYST:
TELEPHONE: 747-444-6104
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/27/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/27/2025


LIC809 (FAS) - (06/04)
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