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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609827
Report Date: 09/03/2026
Date Signed: 09/03/2026 02:23:55 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 09/03/2026 02:23 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:VIP SENIOR LIVING LLCFACILITY NUMBER:
197609827
ADMINISTRATOR/
DIRECTOR:		AYLLON, MADELEINEFACILITY TYPE:
740
ADDRESS:5457 WOODMAN AVETELEPHONE:
(818) 994-4116
CITY:SHERMAN OAKSSTATE: CAZIP CODE:
91401
CAPACITY: 6CENSUS: 6DATE:
09/03/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:51 AM
MET WITH:Jeffrey Alvarez - LicenseeTIME VISIT/
INSPECTION COMPLETED:
02:35 PM
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Licensing Program Analyst (LPA) Quoc Huynh arrived at the facility unannounced to conduct a required annual visit at 9:51AM. The LPA met with Staff Merle Pacada. The Licensee Jeffrey Alvarez arrived at 1:01PM. Entrance interview conducted.

Beginning at 10:19AM, the LPA and Staff toured the physical plant areas inside and outside to ensure there were no health and safety hazards, and the facility is in compliance with Title 22 Regulations. The following was observed:

KITCHEN: Knives were stored inaccessible in a locked drawer near the sink with cleaning supplies stored inaccessible and locked under the sink. Kitchen appliances were in operable condition. The facility had a supply of perishable and non-perishable food. Food in the refrigerator and freezer were observed to be properly stored and labeled. The LPA observed an unsecured pair of scissors in a drawer and cockroaches in the kitchen. The Staff explained that Staff spray the kitchen when they see cockroaches.

COMMON AREAS: At the time of the visit, the facility had two (2) living rooms, a dining room, and a den with furniture observed to be in good condition. Dining room cabinets contained unsecured medication pills in a cup. Required postings were in the entryway hallway and the dining room. The LPA observed emergency water stored near the second living room and emergency food stored in a cabinet.

Report Continued on LIC 809-C
Kristin Heffernan
Quoc Huynh
DATE: 09/03/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/03/2026
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: VIP SENIOR LIVING LLC
FACILITY NUMBER: 197609827
VISIT DATE: 09/03/2026
NARRATIVE
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The hallway closet contained extra linens, and the closet doors were in disrepair as they were leaning and not aligned with the closet tracks. The facility maintained a comfortable temperature throughout the visit.

BEDROOMS/RESTROOMS: There were six (6) total bedrooms: two (2) staff rooms and four (4) resident rooms. Bedroom #5 had a direct exit to the outside and was approved for one (1) bedridden resident. One (1) staff room was not secured and contained laundry detergent and staff medications that were accessible to residents. Bedrooms were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. Full bed rails were observed on four (4) resident beds. There were four (4) total restrooms in the facility: two (2) staff restrooms, one (1) private resident restroom, and one (1) shared resident restroom in the hallway. Restrooms were relatively clean and sanitary and in operating condition with grab bars and non-slip surfaces. All restrooms were sufficiently stocked with soap, paper products, and displayed hand washing signs. The shared resident restroom contained a closet with extra linens. Hot water was tested and measured between 138.4 degrees F and 139.5 degrees F, which was not in the required range of 105 degrees F and 120 degrees F. Window screens were observed to be in disrepair or missing from the windows in resident rooms and restrooms.

OUTDOOR AREA: The surrounding grounds had one (1) shaded patio areas equipped with furniture in good condition for residents and visitors to use. There were two (2) manual driveway gates, and two (2) self-latching gates used for emergencies. No bodies of water noted, and exits were free of obstructions. The rear had laundry machines that were observed to be operational with a nearby garage. The garage contained general storage and was inaccessible.

RECORDS: Record review began at 11AM. Resident records were reviewed for, but not limited to care plans, physician's report, admissions agreement, and consent forms. Three (3) residents’ Appraisal/Needs and Services Plans were not signed.

Report Continued on LIC 809-C
NAME OF LICENSING PROGRAM MANAGER: Kristin Heffernan
NAME OF LICENSING PROGRAM ANALYST: Quoc Huynh
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/03/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/03/2026
LIC809 (FAS) - (06/04)
Page: 3 of 11
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: VIP SENIOR LIVING LLC
FACILITY NUMBER: 197609827
VISIT DATE: 09/03/2026
NARRATIVE
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Record review also revealed that one (1) resident who had full bed rails were not on hospice. Personnel records were reviewed for, but not limited to health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. Staff training was missing two (2) hours of dementia, two (2) hours of medication, and the required restricted health conditions, hospice, and postural support topics.

INFECTION CONTROL/EMERGENCY DISASTER PLAN: During today's visit, LPA reviewed the facility's emergency disaster plan and infection control plan. Both plans were not reviewed annually. Emergency disaster drills are conducted quarterly, with the last documented drill on 07/17/2026. Smoke and carbon monoxide detectors were tested at 11:55AM and were operational at the time of the visit. Two (2) fire extinguishers were observed throughout the facility and were last serviced on 05/27/2026.

MEDICATIONS: Medication review began at 12:17PM. Medications were centrally stored and kept inaccessible in the hallway cabinet located between the staff room and staff restroom. Medications were observed for two (2) residents. Medications were labeled and checked for expiration dates and were properly documented on the centrally stored medication and destruction record. Resident medications were observed to be prepared in advance in pill organizers. The LPA advised the Staff that they are no longer allowed to prepare medications.

Three (3) civil penalties in the total amount of $750 were assessed for repeat violations within a twelve (12) month period (Refer to LIC 421FC). The Licensee was advised that failure to correct and continued violation may result in additional civil penalties.

Pursuant to Title 22 CA Code of Regulations, the following deficiencies were cited (Refer to LIC 809-D).

Exit interview conducted. A copy of the appeal rights and report were reviewed and provided.
NAME OF LICENSING PROGRAM MANAGER: Kristin Heffernan
NAME OF LICENSING PROGRAM ANALYST: Quoc Huynh
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/03/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/03/2026
LIC809 (FAS) - (06/04)
Page: 4 of 11
Document Has Been Signed on 09/03/2026 02:23 PM - It Cannot Be Edited


Created By: Quoc Huynh On 09/03/2026 at 01:03 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: VIP SENIOR LIVING LLC
FACILITY NUMBER: 197609827

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/03/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/04/2026
Section Cited
CCR
87303(e)(2)

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(2) Faucets used by residents for personal care… 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 was not met as evidenced by:
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The Licensee will lower the water temperature and provide CCLD with video proof measuring the hot water.
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Based on observation, the license did not comply with the above section in hot water temperatures were not withtin the required range which posed an immediate health, safety, and personal rights risk to persons in care.
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Type A
09/04/2026
Section Cited
CCR87309(a)

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(a) Except as specified in subsection (b), the licensee shall ensure that … sharp objects… which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage.

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The staff secured the scissors during the visit. POC cleared.
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Based on observation, the licensee did not comply with the above section in sharp objects were not secured which posed an immediate health, safety, and personal rights risk to persons in care.
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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.
Kristin Heffernan
NAME OF LICENSING PROGRAM MANAGER:
Quoc Huynh
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/03/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/03/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/03/2026 02:23 PM - It Cannot Be Edited


Created By: Quoc Huynh On 09/03/2026 at 01:08 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: VIP SENIOR LIVING LLC
FACILITY NUMBER: 197609827

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/03/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/04/2026
Section Cited
HSC
1569.618(c)(4)

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(4) Ensure that the facility is clean, safe, sanitary, and in good repair at all times.

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The Licensee temporarily removed the hazards and will replace the staff's door lock for an operational one and provide proof to CCLD by POC due date.
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Based on observation, the licensee did not comply with the above section in the staff room was not secured and staff had personal medications laying around the facility which posed an immediate health and safety risk to persons in care.
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Type A
09/04/2026
Section Cited
CCR87465(h)(2)

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(2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to person other than employees responsible for the supervision of the centrally stored medication.

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The Licensee will destroy the unused medications and submit proof to CCLD with a statement of understanding by POC due date.
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Based on observation, the licensee did not comply with the above section in resident medication pills were stored accessible in a cup which posed an immediate health and safety risk to persons in care.
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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.
Kristin Heffernan
NAME OF LICENSING PROGRAM MANAGER:
Quoc Huynh
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/03/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/03/2026


LIC809 (FAS) - (06/04)
Page: 6 of 11
Document Has Been Signed on 09/03/2026 02:23 PM - It Cannot Be Edited


Created By: Quoc Huynh On 09/03/2026 at 01:16 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: VIP SENIOR LIVING LLC
FACILITY NUMBER: 197609827

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/03/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/24/2026
Section Cited
CCR
87303(a)

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(a) The facility shall be clean, safe, sanitary and in good repair at all times. …

This requirement was not met as evidenced by:
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The Licensee will repair the closet doors and conduct a deep cleaning of the facility and provide proof to CCLD by POC due date.
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Based on observation, the licensee did not comply with the above section in the hallway closet doors were in disrepair and the facility was not maintained in a clean state which resulted in pests which posed a potential health and safety risk to persons in care.
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Type B
09/17/2026
Section Cited
CCR87303(c)

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(c) All window screens shall be clean and maintained in good repair.

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The Licensee will repair all window screens and provide proof to CCLD by POC due date.
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Based on observation, the licensee did not comply with the above cited section restroom and bedroom window screens were in disrepair or missing which posed a potential health, safety, and personal rights risk to persons in care.
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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.
Kristin Heffernan
NAME OF LICENSING PROGRAM MANAGER:
Quoc Huynh
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/03/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/03/2026


LIC809 (FAS) - (06/04)
Page: 7 of 11
Document Has Been Signed on 09/03/2026 02:23 PM - It Cannot Be Edited


Created By: Quoc Huynh On 09/03/2026 at 01:20 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: VIP SENIOR LIVING LLC
FACILITY NUMBER: 197609827

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/03/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/17/2026
Section Cited
CCR
87470(d)(6)

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87470(d)(6) The Emergency Infection Control Plan shall be reviewed and updated as necessary or whenever new infection control measures are recommended…

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The Licensee will provide CCLD with a signed/reviewed infection control plan and submit a statement of understanding by POC due date.
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Based on record review, the licensee did not comply with the above section in the infection control plan was not reviewed annually which posed a potential health and safety risk to persons in care.
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Type B
09/17/2026
Section Cited
HSC1569.695(d)

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d) A facility shall review the plan annually and make updates as necessary… The licensee or administrator shall sign and date documentation to indicate that the plan has been reviewed and updated as necessary.

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The Licensee will provide CCLD with a signed/reviewed infection control plan and submit a statement of understanding by POC due date.
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Based on record review, the licensee did not comply with the section above in the emergency disaster plan was not reviewed annually which posed a pottential health and safety risk to persons in care.
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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.
Kristin Heffernan
NAME OF LICENSING PROGRAM MANAGER:
Quoc Huynh
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/03/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/03/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/03/2026 02:23 PM - It Cannot Be Edited


Created By: Quoc Huynh On 09/03/2026 at 01:23 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: VIP SENIOR LIVING LLC
FACILITY NUMBER: 197609827

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/03/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/17/2026
Section Cited
HSC
1569.625(b)(2)

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(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training… four hours of which shall be specific to postural supports, restricted health conditions, and hospice care…

This requirement was not met as evidenced by:
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The Licensee will provide staff with the remaining training and provide proof to CCLD by POC due date.
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Based on record review, the licensee did not comply with the above section in staff did not receive the required training topics and hours which posed a potential health, safety, and personal rights risk to persons in care.
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Type B
09/17/2026
Section Cited
HSC1569.69(b)

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(b) Each employee who received training… and who continues to assist with the self-administration of medicines, shall also complete eight hours of in-service training on medication-related issues in each succeeding 12-month period.

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The Licensee will provide staff with the required training and provide proof to CCLD by POC due date.
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Based on record review, the licensee did not comply with the above section in staff did not receive the hours which posed a potential health, safety, and personal rights risk to persons in care.
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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.
Kristin Heffernan
NAME OF LICENSING PROGRAM MANAGER:
Quoc Huynh
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/03/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/03/2026


LIC809 (FAS) - (06/04)
Page: 9 of 11
Document Has Been Signed on 09/03/2026 02:23 PM - It Cannot Be Edited


Created By: Quoc Huynh On 09/03/2026 at 01:26 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: VIP SENIOR LIVING LLC
FACILITY NUMBER: 197609827

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/03/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/17/2026
Section Cited
CCR
87506(a)

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(a) The licensee shall ensure that a separate, complete, and current record in maintained for each resident…

This requirement was not met as evidenced by
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The Licensee will obtain signatures on the residents' Appraisals and provide CCLD proof by POC due date.
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Based on record review, the licensee did not comply with the above section in 3 residents did not have a complete Appraisal with signatures which posed a potential health, safety, and personal rights risk to persons in care.
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Type B
09/03/2026
Section Cited
CCR00

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Intentaionally left blank
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Intentaionally left blank

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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.
Kristin Heffernan
NAME OF LICENSING PROGRAM MANAGER:
Quoc Huynh
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/03/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/03/2026


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Document Has Been Signed on 09/03/2026 02:23 PM - It Cannot Be Edited


Created By: Quoc Huynh On 09/03/2026 at 01:30 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: VIP SENIOR LIVING LLC
FACILITY NUMBER: 197609827

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/03/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/17/2026
Section Cited
CCR
87608(a)(5)(B)

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(B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails.

This requirement was not met as evidenced by:
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The Licensee will remove the resident's full bed rails and provide CCLD proof by POC due date.
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Based on observation and record review, the licensee did not comply with the section above in 2 residents had full bed rails and were not on hospice which posed a pottential health and safety risk to persons in care.
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ILS


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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.
Kristin Heffernan
NAME OF LICENSING PROGRAM MANAGER:
Quoc Huynh
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/03/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/03/2026


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