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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610375
Report Date: 09/26/2025
Date Signed: 09/26/2025 04:46:38 PM

Document Has Been Signed on 09/26/2025 04:46 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:ELITE RETIREMENT RESIDENCEFACILITY NUMBER:
197610375
ADMINISTRATOR/
DIRECTOR:		BERKOWITZ,DENISEFACILITY TYPE:
740
ADDRESS:6900 ROYER AVENUETELEPHONE:
(818) 640-2475
CITY:WEST HILLSSTATE: CAZIP CODE:
91307
CAPACITY: 6CENSUS: 6DATE:
09/26/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:30 PM
MET WITH:Denise BerkowitzTIME VISIT/
INSPECTION COMPLETED:
03:45 PM
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At approximately 12:30 p.m. on 09/26/25 Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced annual inspection. LPA met with the administrator and disclosed the reason for the visit.

The facility was last visited on 07/31/2024 for an annual inspection. It is a single story building with six (06) bedrooms, four (04) bathrooms, kitchen, common areas, and outdoor areas. It has an approved fire clearance for six (06) residents, of which four (04) may be ambulatory and two (02) may be non-ambulatory with one (01) bedridden in Bedroom #5. Approved hospice waivers for three (03).

At the main entrance, LPA observed a maintained front yard. Postings for resident rights, confidential complaint contacts, ombudsman contacts, facility sketch, and license were observed near the front. A binder contained additional required postings. A screening station contained hand sanitizer, masks, and a visitor log.

The facility has six (06) bedrooms. One (01) bedroom is designated as a staff room. The staff room was free of hazards. Bedrooms contained beds with adequate bedding, chairs, nightstands, night lights, and sufficient storage space. All furnishings were clean and in good condition. Beds had wheels in the locked position. The facility has four (04) bathrooms. Bathrooms contained liquid soap, paper towels or personal towels, trash can, grab bars near the toilet and shower, commodes, shower chairs, and a non-skid surface in the shower. At approximately 12:45 p.m. LPA measured the water temperature to be 108 degrees Fahrenheit in the front bathroom. A hallway closet contained adequate amounts of fresh linens and hygiene supplies. At approximately 12:50 p.m., the room temperature was measured to be 72 degrees Fahrenheit.

LPA observed an adequate supply of perishable and non-perishable foods in the refrigerator. At 1:10 p.m. the refrigerator and freezer temperatures were measured to be 35 and -2 degrees Fahrenheit, respectively.

NAME OF LICENSING PROGRAM MANAGER: Naira Margaryan
NAME OF LICENSING PROGRAM ANALYST: Nicholas Reed
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/26/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/26/2025
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: ELITE RETIREMENT RESIDENCE
FACILITY NUMBER: 197610375
VISIT DATE: 09/26/2025
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The stove hood was clean. Appliances were new and in good condition. Sharps, cleaning solutions, and a complete first aid kit were locked below the counter. Medications were locked above the counter top. At approximately 1:15 p.m. LPA observed a fully charged fire extinguisher in the kitchen with a receipt attached. A washing machine and dryer were located near the kitchen. Both were in working order. Detergents were locked in the laundry room with the appliances. Walls, floors, windows, screens, and blinds were clean and in good repair.

LPA observed a covered patio area in the rear of the facility. The patio contained furniture in good condition. The ramp leading out from the bedridden room was free of hazards and had secure handrails. The emergency exit path was free from obstructions. The exit gate was unlocked with self-closing latches. Evacuation routes were posted. At approximately 2:45 p.m., smoke and carbon monoxide detectors were tested and operational.

At approximately 1:30 p.m., LPA conducted a record review of resident and personnel files. Staff files were incomplete and not all available for audit. A deficiency are issued for the licensee not maintaining complete records for all staff. Additionally, a review of Guardian at approximately 2:00 p.m. revealed that only the licensee and administrator were associated to the facility. The administrator noted that all staff have fingerprints and background checks, but most staff files were at the agency. The staff present was not associated to the facility and had worked for about one month. An additional deficiency is issued today along with a civil penalty of $500 for staff present in the facility without an association to the facility.

Exit interview conducted. Appeal rights discussed. Copy of report provided.

NAME OF LICENSING PROGRAM MANAGER: Naira Margaryan
NAME OF LICENSING PROGRAM ANALYST: Nicholas Reed
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/26/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/26/2025 04:46 PM - It Cannot Be Edited


Created By: Nicholas Reed On 09/26/2025 at 02:42 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: ELITE RETIREMENT RESIDENCE
FACILITY NUMBER: 197610375

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/26/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87355(e)(3)
87355 Criminal Record Clearance (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 87355(c)

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 in one (01) out of three (03) staff which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/29/2025
Plan of Correction
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Licensee to transfer the criminal background clearance of Staff #1 (S1) to the facility and associate the staff.
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.
Naira Margaryan
NAME OF LICENSING PROGRAM MANAGER:
Nicholas Reed
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/26/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/26/2025


LIC809 (FAS) - (06/04)
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