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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610009
Report Date: 03/23/2026
Date Signed: 03/23/2026 04:29:12 PM

Document Has Been Signed on 03/23/2026 04:29 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:TEESDALE VILLA RCFEFACILITY NUMBER:
197610009
ADMINISTRATOR/
DIRECTOR:		GUEVARRA, JOSE JR.FACILITY TYPE:
740
ADDRESS:7663 TEESDALE AVENUETELEPHONE:
(747) 203-1478
CITY:NORTH HOLLYWOODSTATE: CAZIP CODE:
91605
CAPACITY: 6CENSUS: 4DATE:
03/23/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:14 AM
MET WITH:Jose GuevarraTIME VISIT/
INSPECTION COMPLETED:
04:30 PM
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Licensing Program Analyst (LPA) Trevor Byrne arrived at the facility unannounced to conduct the required annual visit at 10:14 AM. LPA met with facility staff and contacted the Administrator Jose Guevarra Jr. The Administrator arrived to the facility at 10:56 AM. Entrance interview conducted and the reason for the visit was explained.

Beginning at 10:31 AM, the LPA 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 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 drawer which contained knives and other sharp objects. LPA observed a fire extinguisher to be fully charged and last serviced on 01/05/2026. LPA observed adequate emergency food and water supplies stored in the kitchen.

BEDROOMS: There are six (6) bedrooms in the facility; two (2) are dual occupancy resident rooms, one (1) is a single occupancy resident room, and three (3) are staff rooms. LPA toured all six (6) bedrooms. All resident rooms were observed to be furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting. Bedrooms #4 and #5 were observed to contain direct exits to the outside of the facility. Bedroom #3 is a staff room that was observed to be unlocked and contained an unsecured bottle of disinfectant spray.

CONTINUED ON LIC 809C.

NAME OF LICENSING PROGRAM MANAGER: Kasandra Lopez
NAME OF LICENSING PROGRAM ANALYST: Trevor Byrne
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 03/23/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/23/2026
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.

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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: TEESDALE VILLA RCFE
FACILITY NUMBER: 197610009
VISIT DATE: 03/23/2026
NARRATIVE
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COMMON AREAS: This included the living room, hallway, laundry room, and dining area. LPA observed the living room to be clean and in good repair. The living room contained adequate activities and adequate seating for resident use. LPA observed the living room to contain an adequately screened fireplace. LPA observed the hallway to contain an appropriately secured closet which contained the facility’s complete first aid kit, resident medications, and facility files. LPA observed an additional hallway closet which contained resident clothing/linens. LPA observed the laundry room to be locked and inaccessible to clients in care. The laundry room contained a washer and dryer, laundry chemicals, cleaning chemicals, and extra linens. LPA observed the dining area to be clean and properly furnished at the time of the visit. The dining area contained a dining table with adequate seating for resident use. LPA observed cameras located throughout the common areas of the facility, LPA confirmed with the facility Administrator that audio is not recorded. The facility’s combination fire and carbon monoxide alarms were tested at 01:00 PM and were functional at the time of the visit.

BATHROOMS: There are three (3) bathrooms at the facility. One (1) bathroom is designated as private resident bathroom, and two (2) bathrooms are designated as shared resident bathrooms. All resident bathrooms were observed to be clean and in good repair and were equipped with nonskid surfaces. Grab bars were observed in all resident showers and near all resident toilets, all were properly secured. The water temperature was measured between 115.6 and 116.6 degrees Fahrenheit, which is within the range required by regulation. LPA observed a hallway bathroom to contain unsecured grooming supplies.

OUTDOOR SPACE: The facility has two (2) emergency exit gates. One (1) is located in the front yard and one (1) is located on the side of the home; LPA observed clear passageways for emergency exit use. The gate on the north side of the facility’s backyard is not an emergency exit gate and leads to the yard of an attached ADU. The facility had adequate shaded seating outdoors for resident use. LPA observed one (1) storage shed in the backyard of the facility. LPA observed the storage shed to contain unsecured cleaning supplies, pesticides, and gardening tools. LPA informed the Administrator 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. The Administrator expressed understanding and secured the items at the time of the visit.

CONTINUED ON LIC 809C.

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

DATE: 03/23/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/23/2026
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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: TEESDALE VILLA RCFE
FACILITY NUMBER: 197610009
VISIT DATE: 03/23/2026
NARRATIVE
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RECORD REVIEW: Record review began at 10:58 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 documentation of their initial 40-hours of training. Four (4) resident files were reviewed. LPA observed four (4) resident files contained Appraisal Needs and Services Plans that were last updated more than twelve (12) months prior. LPA informed the Administrator that appraisals shall be updated in writing as frequently as necessary or once every 12 months, whichever occurs first. The Administrator expressed understanding and agreed to complete an updated appraisal for each resident and to send proof of the completed appraisal to Community Care Licensing Division.

MEDICATION REVIEW: Medication review began at 12:42 PM. Medications for four (4) of four (4) 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 they pertain to infection control are adequate. Emergency disaster drills are to be conducted quarterly; the facility’s last emergency disaster drill was conducted on 12/05/2025 which is outside of the required timeframe. 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 Administrator.

INTERVIEWS: LPA attempted to interview two (2) residents. The residents did not express any concerns with the facility. LPA interviewed one (1) staff member. The staff member interviewed was knowledgeable on their role and responsibilities, the resident’s rights, the forms of abuse, and the appropriate reporting procedures for suspected abuse.

During today’s visit LPA obtained a copy of the facility’s emergency disaster plan, LIC 500, resident roster, and 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.

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

DATE: 03/23/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/23/2026
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/23/2026 04:29 PM - It Cannot Be Edited


Created By: Trevor Byrne On 03/23/2026 at 03:20 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: TEESDALE VILLA RCFE
FACILITY NUMBER: 197610009

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/23/2026

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
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Based on observation, the licensee did not comply with the section cited above as the facility shed, an unlocked staff bedroom, and a hallway bathroom contained unsecured items including cleaning supplies, gardening tools, and grooming supplies which poses an immediate health and safety risk to persons in care.
POC Due Date: 03/23/2026
Plan of Correction
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Administrator secured the items at the time of the visiit. POC cleared.
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.
Kasandra Lopez
NAME OF LICENSING PROGRAM MANAGER:
Trevor Byrne
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 03/23/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/23/2026


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Document Has Been Signed on 03/23/2026 04:29 PM - It Cannot Be Edited


Created By: Trevor Byrne On 03/23/2026 at 03:20 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: TEESDALE VILLA RCFE
FACILITY NUMBER: 197610009

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/23/2026

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
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Based on record review, the licensee did not comply with the section cited above as one staff member did not have proof of completed initial trainings logged in their staff file which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/06/2026
Plan of Correction
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Administrator agreed to appropriately log the trainings that the staff member completed and to send proof of the appropriately logged trainings 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: 03/23/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/23/2026


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Document Has Been Signed on 03/23/2026 04:29 PM - It Cannot Be Edited


Created By: Trevor Byrne On 03/23/2026 at 04:06 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: TEESDALE VILLA RCFE
FACILITY NUMBER: 197610009

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/23/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87463(a)
(a) The pre-admission appraisal, as specified in Section 87457, Pre-Admission Appraisal, shall be updated, in writing as frequently as necessary or once every 12 months, whichever occurs first, to note significant changes in condition, as defined in Section 87101, Definitions, and to keep the appraisal accurate. For the purposes of this section, the updated pre-admission appraisal shall be referred to as the reappraisal.

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 four resident files contained appraisals which were last updated more than 12 months prior which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/06/2026
Plan of Correction
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Administrator agreed to complete updated appraisals for the identified individuals and to send proof of the completed appraisals to CCLD no later than POC due date.
Type B
Section Cited
HSC
1569.695(c)
(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 last emergency disaster drill was completed more than three months prior which poses a potential safety risk to persons in care.
POC Due Date: 04/06/2026
Plan of Correction
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Administrator agreed to complete an emergency disaster drill and to send proof of the completed drill 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: 03/23/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/23/2026


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