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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610540
Report Date: 08/06/2025
Date Signed: 08/06/2025 09:01:27 AM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 08/06/2025 09:01 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.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:NINA RESIDENTIAL HOMEFACILITY NUMBER:
197610540
ADMINISTRATOR/
DIRECTOR:		ACHIENG, ANTONIAFACILITY TYPE:
735
ADDRESS:18215 SEPTO STTELEPHONE:
(818) 678-9325
CITY:NORTHRIDGESTATE: CAZIP CODE:
91325
CAPACITY: 4CENSUS: 4DATE:
08/06/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
07:40 AM
MET WITH:Antonia Achieng, AdministratorTIME VISIT/
INSPECTION COMPLETED:
09:05 AM
NARRATIVE
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On 08/06/25, at 7:40am, Licensing Program Analyst (LPA) Gina Saucedo arrived at the facility to conduct an unannounced, annual visit. LPA met with Antonia Achieng, Administrator.

LPA asked for the census, client, and staff rosters. The administrator stated there are no clients and/or staff at the facility.

The facility has been licensed as an Adult Residential Facility (ARF) and level four (4). The requested capacity is for four (4) clients. The physical plant was toured inside and outside at 8:00am. It is a single, story home.

Kitchen area: was sufficiently stocked with seven (7) days of perishable and seven (7) days of non-perishable food. There is one (1) refrigerator in the kitchen area. The cabinets have canned goods. Sharps are kept secured and locked in one (1) of the cabinets under the sink. The fire extinguisher was observed to be full and dated 08/05/25.

The medication will be kept at the entrance of the facility on your left hand side locked and secured. The medication pantry is currently empty with no medications due to the facility having no clients. The first aid is also kept in the same pantry.

LIC 809C-continued
NAME OF LICENSING PROGRAM MANAGER: Troy Agard
NAME OF LICENSING PROGRAM ANALYST: Gina Saucedo
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 08/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/06/2025
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.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: NINA RESIDENTIAL HOME
FACILITY NUMBER: 197610540
VISIT DATE: 08/06/2025
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Bedrooms/Bathrooms: There is a total of four (4) bedrooms and two (2) and half bathrooms. One (1) of the bedrooms has a private bathroom. There is another bathroom in the hallway and a half-bathroom where the washer and dryer are located. The hot water temperature was tested and measured between 118 and 120 degrees. All the bedrooms have proper bedding, chairs, nightstands, lamps in addition to overhead lighting. There is adequate supply of linen stored in one (1) of the cabinets in the hallway.

There is an office area on your left-hand entrance of the facility next to the kitchen. There is another refrigerator and a freezer in this area.

There is one (1) washer and dryer with chemicals kept kitchen area locked in a pantry area.

Living Room and Dining Room: There is enough seating for staff and clients. The furniture is in good condition. The client/staff files will be kept in a closet at the entrance of the facility where the medication and first aid are locked, secured and inaccessible to the clients.

Outside/Backyard: The garage can be accessed through the office area. The outside/backyard has furniture for clients to have proper seating. The facility has no signal system.

No firearms observed or will be maintained on the premises. The smoke alarm and carbon monoxide detector were tested and operational. They are hardwired. The facility has a current telephone landline and internet access. The facility temperature was at 75 degree Fahrenheit.

Administration:


There are signs against the wall at the entrance of the facility on your right-hand side. The YES sign, Facility sketch, Emergency and Disaster Plan.

An exit interview was conducted, no citation(s) were issued, and a copy of this report was given to the administrator.
NAME OF LICENSING PROGRAM MANAGER: Troy Agard
NAME OF LICENSING PROGRAM ANALYST: Gina Saucedo
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2025
LIC809 (FAS) - (06/04)
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