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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610163
Report Date: 09/26/2026
Date Signed: 09/26/2026 03:28:20 PM

Document Has Been Signed on 09/26/2026 03:28 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 S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:A & V SENIOR CAREFACILITY NUMBER:
197610163
ADMINISTRATOR/
DIRECTOR:		GONZALEZ, LORENAFACILITY TYPE:
740
ADDRESS:14928 HIAWATHA STREETTELEPHONE:
(818) 921-0589
CITY:MISSION HILLSSTATE: CAZIP CODE:
91345
CAPACITY: 6CENSUS: 5DATE:
09/26/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:22 PM
MET WITH:Rosavilla Lagayada - StaffTIME VISIT/
INSPECTION COMPLETED:
03:30 PM
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Licensing Program Analysts (LPA) Jose Tan conducted an unannounced Required One (1) year visit to this facility. LPA met with staff Rosaivlla Lagayada who called the Administrator designee Susan Nuguid and explained the reason for the visit. Ms. Nuguid designated Ms. Lagayada to sign the report.

There is only one entrance being utilized at the facility. The facility had submitted and approved Infection Control and Mitigation plan. The screen door however has a broken handle. The facility has a designated visitors' area at the backyard. The facility has sufficient stock of PPE in the storage room.

At 12:31 PM, tour of the physical plant was conducted with the staff. This facility is a single storey house and has five (5) bedrooms and two (2) bathrooms currently occupying five (5) residents. One (1) bedroom is designated for staff use. The facility is fire cleared for six (6) ambulatory residents, four (4) of which may be non-ambulatory and one (1) maybe bedridden in Room #5, hospice waiver for six (6) residents.

Physical environment was checked for cleanliness and condition. Walls, windows, ceilings, floors and floor coverings, and doors were checked, the following was noted:

Living and dining room furniture were also checked. The living room is neat and clean along with the dining room. The facility maintains a comfortable temperature at 74°F. The smoke detector is hardwired, tested and observed to be operational. There are two (2) fire extinguishers located in the kitchen. Both extinguishers are observed to be full and last checked on 10/23/25. There is carbon monoxide detector installed at the facility. (continued on LIC 809-C)
Troy Agard
Jose Gary Tan
DATE: 09/26/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/26/2026
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 3
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: A & V SENIOR CARE
FACILITY NUMBER: 197610163
VISIT DATE: 09/26/2026
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(continued from LIC 809-C)

The backyard of the facility has outdoor furniture, with a covered shaded area for clients. There is no body of water in the facility. There is a shed located in the other side of the backyard currently being used as an old equipment storage and observed to be locked and inaccessible to residents.

Food Service/Kitchen area was sufficiently stocked with two (2) days perishable and seven (7) days non-perishable food. Frozen foods are properly wrapped and stored appropriately. Food storage and preparation areas are clean and inaccessible to pests. Cleaning supplies, laundry detergents, pesticides or toxins were stored in the kitchen cabinet and observed to be locked and inaccessible to residents. All sharps and knives were also observed to be locked in a kitchen cabinet. Laundry area is located adjacent to the kitchen. Laundry detergent and other cleaning agents are observed to be locked in a cabinet in the laundry area.

The Clients' rooms are adequately furnished with appropriate furniture and lighting system. Hall ways/passage ways are lit to non-private rooms. Clients have sufficient amounts of personal hygiene product which is provided by the licensee. Staff Rooms: Staff room was observed to be locked. No medications are observed in the staff room.

The bathrooms were checked for cleanliness and proper operation. LPA observed the appropriate grab bars for each toilet, bathtub and shower. The hot water temperature measured at a range of 110.1°F to 116.8°F. Towels and washcloths are not shared. There is enough clean linen available in stock at the cabinet.



Medications: LPA observed medication in the kitchen cabinet to be locked and inaccessible to residents. Medications are listed on the centrally stored medication and destruction record. There are two (2) complete first aid kits located in the medication cabinet.

Client and Staff records all residents and staff present records were reviewed. Residents and staff record appeared to be complete and updated.

Disaster drill was last conducted on 09/12/26. Required posting are observed to be complete and current and displayed properly at the facility. Exit interview conducted and copy of this report issued.
NAME OF LICENSING PROGRAM MANAGER: Troy Agard
NAME OF LICENSING PROGRAM ANALYST: Jose Gary Tan
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/26/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2026
LIC809 (FAS) - (06/04)
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