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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609871
Report Date: 04/08/2026
Date Signed: 04/08/2026 03:32:37 PM

Document Has Been Signed on 04/08/2026 03:32 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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:HEPZEBAH HOUSEFACILITY NUMBER:
197609871
ADMINISTRATOR/
DIRECTOR:		JACKSON, SYLVIAFACILITY TYPE:
740
ADDRESS:22230 VANOWEN STTELEPHONE:
(310) 213-4927
CITY:WOODLAND HILLSSTATE: CAZIP CODE:
91303
CAPACITY: 6CENSUS: 5DATE:
04/08/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:45 AM
MET WITH:Sylva Jackson, AdministratorTIME VISIT/
INSPECTION COMPLETED:
03:30 PM
NARRATIVE
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At 11:45am, Licensing Program Analysts (LPAs), Angela Panushkina and Huma Rahimi conducted an unannounced annual inspection at the facility mentioned above. LPAs met with the Administrator and explained the reason for the visit.

Facility is licensed for capacity of six (6) Non-Ambulatory, of which one (1) may be Bedridden in room #1 only. Hospice waiver is granted for two (2) residents.

At approximately 12:00pm, LPAs toured the kitchen area and observed enough supplies of staple non-perishable for minimum 1 week and perishable for 2 days at the facility. All knives and sharps are observed to be locked in a kitchen drawer and inaccessible to residents. There is a fire extinguisher in the kitchen was fully charged.

LPAs observed five (5) bedrooms designated for residents’ use. All bedrooms have sufficient lighting, properly furnished, clean and have appropriate bedding and linens. Auditory alarms were tested and observed to be operational. Facility also has awake staff at night.

There are two (2) full bathrooms. All bathrooms were observed to be clean and in good repair. Properly supplied with toilet paper, soap and paper towels. The hot water temperature measured at 105.8°F. LPAs observed appropriate grab bar and non-skid mat. All trash cans in bathrooms had fitted lids to protect them from cross contamination.

The facility maintains a comfortable temperature at 75°F. The Common areas are furnished with adequate furniture to accommodate a maximum capacity of six (6) residents.
Continue on LIC809-C

NAME OF LICENSING PROGRAM MANAGER: Nichelle Gillyard
NAME OF LICENSING PROGRAM ANALYST: Angela Panushkina
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/08/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/08/2026
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 4
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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: HEPZEBAH HOUSE
FACILITY NUMBER: 197609871
VISIT DATE: 04/08/2026
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At approximately 12:30pm, LPAs observed medications are centrally stored and locked in the kitchen cabinet, and inaccessible to residents in care. The first-aid kit has been inspected which has at least the following: tweezers, scissors, antiseptic, bandages, gauze, thermometer; including a current First Aid manual.

The laundry is located by the kitchen. The washer/dryer appears to be in good condition. Laundry supplies are kept inaccessible when not in use with supervision.

At 12:50pm, smoke and carbon monoxide detectors were tested and observed to be operable.

At 1:00pm, LPAs toured the outside area of the facility. LPAs observed appropriate outdoor furniture, with a covered shaded area for residents. The outdoor area was free of visible immediate hazards. LPAs discussed the importance of maintaining care and supervision to meet the needs of residents.

Between 1:10pm to 2:00pm, LPAs reviewed records of five (5) residents and two (2) staff. Client and staff records appeared to be complete and updated. LPAs were informed that no Certificate of Liability Insurance is available at this time and will be provided to the department within two (2) weeks.

Deficiency issued during this visit.

Exit interview conducted and copy of this report signed.

NAME OF LICENSING PROGRAM MANAGER: Nichelle Gillyard
NAME OF LICENSING PROGRAM ANALYST: Angela Panushkina
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/08/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2026
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/08/2026 03:32 PM - It Cannot Be Edited


Created By: Angela Panushkina On 04/08/2026 at 01:49 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., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: HEPZEBAH HOUSE
FACILITY NUMBER: 197609871

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/08/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.605
Liability insurance; coverage requirements On and after July 1, 2015, all residential care facilities for the elderly...shall maintain liability insurance covering injury to residents and guests...

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview, the licensee did not comply with the section cited above by failing to obtain/maintain liability insurance as required, which poses a potential health, safety, and personal rights risk to persons in care.
POC Due Date: 04/15/2026
Plan of Correction
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Licensee will review the health and safety code, obtain liability insurance as required by the health and safety code. Copy of the current liability insurance certificate will be submitted to LPA by POC date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Nichelle Gillyard
NAME OF LICENSING PROGRAM MANAGER:
Angela Panushkina
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/08/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/08/2026


LIC809 (FAS) - (06/04)
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