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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610085
Report Date: 11/01/2025
Date Signed: 11/03/2025 07:31:12 AM

Document Has Been Signed on 11/03/2025 07:31 AM - 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 S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:BELVOIR HOME ADULT RESIDENTIALFACILITY NUMBER:
197610085
ADMINISTRATOR/
DIRECTOR:		REYES, SHARON ROSE PFACILITY TYPE:
735
ADDRESS:9337 BELVOIR AVE.TELEPHONE:
(818) 468-6831
CITY:LA CRESCENTASTATE: CAZIP CODE:
91214
CAPACITY: 4CENSUS: 3DATE:
11/01/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:11 PM
MET WITH:Sharon Reyes - AdministratorTIME VISIT/
INSPECTION COMPLETED:
03:45 PM
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A Required One (1) year visit was conducted today by Licensing Program Analyst (LPA) Jose Tan. LPA met with staff Jesus Payumo who called the Administrator Sharon Reyes and explained the reason for the visit. LPA observed that the two (2) residents were at the facility during visit and the other was at the Day program. This facility is a Frank D Lanterman Regional Center (FDLRC) vendored facility Level IV-G.

A tour of the physical plant was conducted at 12:20 PM and the following was noted:

The front main door is the only entrance being utilized at the facility. Screening area is located immediately upon entrance. Sign in sheet, hand sanitizer, gloves and masks are available. The facility had submitted approved Mitigation and Infection Plan. All trash cans were observed to be with cover.

The facility has a designated visitors' area at the backyard and the partially converted garage. The facility has sufficient stock of PPE in the garage.

The facility is a single storey house and has four (4) bedrooms and two (2) bathrooms. There is no body water in the facility. The facility is fire cleared for four (4) ambulatory residents.

Bedrooms were toured and observed to be clean and properly furnished. Linen storage was also checked and observed to have ample supply of clean linen and towels.
Bathrooms were observed to be clean and sanitary with necessary supplies. Hot water temperature was measured at 115.4°F and within the required range. (continued to LIC 809-C)
NAME OF LICENSING PROGRAM MANAGER: Troy Agard
NAME OF LICENSING PROGRAM ANALYST: Jose Gary Tan
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 11/01/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/01/2025
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 S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: BELVOIR HOME ADULT RESIDENTIAL
FACILITY NUMBER: 197610085
VISIT DATE: 11/01/2025
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(continued from LIC 809)

Physical plant was checked for cleanliness and condition. Facility was in good repair and observed to be clean and free of clutter during today's visit.
Living and dining room furniture were also checked for functionality (wear and tear). Furniture was observed to be in good condition.
Kitchen area was observed to be clean and sanitary and free of pests. Food. The facility is observed to have sufficient food supply for the clients both perishable and non-perishable. Laundry area is located in the garage. Knives and sharps are observed to be locked in the kitchen cabinet. All toxins, cleaning agents and laundry soap are locked in the laundry area cabinet.
Fire extinguisher - There is a fire extinguisher located near the kitchen area. Extinguisher was observed to be operable and last bought on 10/07/25. Dual smoke and carbon monoxide alarms were hardwired and inter-connected, tested and observed to be operational. Temperature of facility wall thermostat was set at 74°F and observed to be within the required range. Garage is attached to the house and partially converted into an office and being used as laundry area, frozen foods and other supplies storage.

Medication was observed to be inaccessible and stored in a secured medication cabinet in the kitchen. There is a complete First Aid kit inside the medication cabinet.



Staff records were reviewed and appeared to be complete and updated. Clients’ records are also reviewed and appeared to be complete and updated.

Disaster drill was last conducted on 10/25/25. Required posting observed in facility (complaint hot line poster, personal rights, etc.).

There was no immediate health and safety hazard observed during the day of inspection. Exit interview conducted and a copy of this report was given.
NAME OF LICENSING PROGRAM MANAGER: Troy Agard
NAME OF LICENSING PROGRAM ANALYST: Jose Gary Tan
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 11/01/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2025
LIC809 (FAS) - (06/04)
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