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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610028
Report Date: 05/22/2025
Date Signed: 05/22/2025 01:31:24 PM

Document Has Been Signed on 05/22/2025 01:31 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:HOLLYWOOD CARE HOMEFACILITY NUMBER:
197610028
ADMINISTRATOR/
DIRECTOR:		LEE, KYONG SUKFACILITY TYPE:
740
ADDRESS:13307 STAGG STREETTELEPHONE:
(909) 618-7575
CITY:N. HOLLYWOODSTATE: CAZIP CODE:
91605
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 0DATE:
05/22/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:36 AM
MET WITH:Kyong Suk LeeTIME VISIT/
INSPECTION COMPLETED:
01:45 PM
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Licensing Program Analysts (LPA) Trevor Byrne arrived at the facility unannounced to conduct a required annual visit at 09:36 AM. LPA spoke on the phone with Administrator Kyong Suk Lee who informed LPA that the facility currently has no residents. Administrator arrived to the facility at 11:23 AM.

Beginning at 11:25 AM, the LPA, along with the Administrator 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:

Fire extinguisher was fully charged and recently serviced on 05/20/2025. Combination smoke and carbon monoxide detectors were tested at 12:30 PM and all were functional at the time of the visit. No fire clearance concerns were observed.

KITCHEN/GARAGE: The LPA observed the garage to be locked and inaccessible. The garage was observed to contain the facility washer and dryer along with tools, care supplies, and household chemicals. The kitchen was observed to be clean. Kitchen appliances appeared to be in operable condition. The facility has a sufficient supply of seven (7) days non-perishable food. No perishable food was observed. Cleaning supplies are located in a locked under-sink cabinet. Medication cabinet was observed to be locked.

COMMON AREAS: This includes the living room and dining room areas. LPA observed common area to be clean and properly furnished at the time of the visit. The living room contained a television. The dining area contained a locked cabinet that contains facility files and adequate seating for resident use. The entryway contained required postings and an infection control point.

Continued on LIC 809C.

Kasandra LopezTELEPHONE: (818) 596-4343
Trevor ByrneTELEPHONE: 747-444-6104
DATE: 05/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/22/2025
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: HOLLYWOOD CARE HOME
FACILITY NUMBER: 197610028
VISIT DATE: 05/22/2025
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BATHROOMS: There are two (2) bathrooms for resident use. Restrooms were observed to be equipped with nonskid surfaces and contain nonskid mats. Grab bars were observed in the bathrooms and all were properly secured. The water temperature was measured in resident bathrooms to be between 129 and 132.8 degrees Fahrenheit.

BEDROOMS: There are 4 (four) total bedrooms in the facility. Three (3) bedrooms were observed to be single occupancy rooms. Bedroom #1 was observed to be missing a bed. All other resident rooms were observed to be furnished appropriately with clean linens, appropriate furnishings and sufficient lighting.

OUTDOOR SPACE: The backyard has patio furniture including a table and chairs for resident use but is not covered. There were no bodies of water on the premises. The entryway ramp and exit ramps located at the back of the facility were observed to lack appropriate safety railings.

EMERGENCY DISASTER PLANNING: During today’s visit, the LPA reviewed the facility's emergency disaster plan. The plan is reviewed/updated annually by the facility’s Administrator.


Due to no residents in care no citations were issued. Although advisory notes were issued to the licensee.

Exit interview conducted and report was issued.

SUPERVISOR'S NAME: Kasandra LopezTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Trevor ByrneTELEPHONE: 747-444-6104
LICENSING EVALUATOR SIGNATURE:

DATE: 05/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2025
LIC809 (FAS) - (06/04)
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