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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610638
Report Date: 05/07/2026
Date Signed: 05/07/2026 12:26:19 PM

Document Has Been Signed on 05/07/2026 12:26 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.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:CHATSWORTH COMMONS SENIOR LIVING, LLCFACILITY NUMBER:
197610638
ADMINISTRATOR/
DIRECTOR:		MONROY, DAVIDFACILITY TYPE:
740
ADDRESS:20801 DEVONSHIRE ST.TELEPHONE:
(818) 341-2552
CITY:CHATSWORTHSTATE: CAZIP CODE:
91311
CAPACITY: 268CENSUS: 160DATE:
05/07/2026
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:45 AM
MET WITH:TIME VISIT/
INSPECTION COMPLETED:
12:55 PM
NARRATIVE
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At 9:45 AM, Licensing Program Analyst (LPA) Huma Rahimi conducted an unannounced Case Management – Incident visit to the facility. A case management report is being issued today in conjunction with complaint control number 31-AS-20260506151957; however, the incident reviewed during today’s visit is not related to the complaint allegations.
On 05/01/2026, Community Care Licensing Division (CCLD), Regional Office (RO), received an incident report regarding a missing resident incident involving Resident #1 (R1) that occurred on 04/23/2026 at approximately 11:45 AM.
According to the report, the Med-Tech on duty notified facility staff that R1 was missing and could not be located within the community. Facility staff conducted a search of R1’s room, surrounding vacant rooms, and interior areas of the facility; however, R1 could not be located. Staff members were alerted, and a community-wide search was initiated.

The Wellness Director searched the surrounding exterior areas while the Maintenance Director drove throughout the nearby community in an attempt to locate R1.

The assigned caregiver reported escorting R1 to the dining room for breakfast and assisting R1 back to the room at approximately 9:00 AM. R1’s roommate reported seeing R1 prior to breakfast but did not observe R1 afterward.

While the Wellness Director was preparing to contact the Los Angeles Police Department (LAPD) to report R1 missing, the facility received a telephone call from LAPD informing the facility that R1 had been located with no apparent injuries. However, the facility transferred R1 to a local hospital for further evaluation.

Continue on LIC 809C

NAME OF LICENSING PROGRAM MANAGER: Nichelle Gillyard
NAME OF LICENSING PROGRAM ANALYST: Huma Rahimi
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/07/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/07/2026
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: CHATSWORTH COMMONS SENIOR LIVING, LLC
FACILITY NUMBER: 197610638
VISIT DATE: 05/07/2026
NARRATIVE
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During today’s visit, LPA reviewed R1’s Physician’s Report dated 04/16/2026 and R1’s Appraisal Needs and Services Plan. LPA observed that R1 has a diagnosis of dementia and that the Physician’s Report specifically documents that R1 is unable to leave the community unsupervised.

LPA conducted an interview with the Administrator, who stated they did not know how R1 exited the facility, despite the facility having an egress door system in place.

Based on records reviewed and statements obtained, the facility failed to provide adequate supervision to R1, resulting in R1 leaving the facility without staff knowledge or assistance despite documented supervision needs and diagnosis of dementia. The facility’s failure to adequately supervise R1 placed R1 at risk of harm.


A deficiency issued and appeal rights explained.

Exit interview conducted and copy this report signed and delivered.

NAME OF LICENSING PROGRAM MANAGER: Nichelle Gillyard
NAME OF LICENSING PROGRAM ANALYST: Huma Rahimi
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/07/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/07/2026
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/07/2026 12:26 PM - It Cannot Be Edited


Created By: Huma Rahimi On 05/07/2026 at 11:08 AM
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: CHATSWORTH COMMONS SENIOR LIVING, LLC
FACILITY NUMBER: 197610638

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/07/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/14/2026
Section Cited
CCR
87705(k)(6)

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87705 (k)(6) The following initial and continuing requirements must be met for the licensee to utilize delayed egress devices on ... (6) Without violating Section 87468, Personal Rights, facility staff shall ensure the continued...This requirement is not met as evidenced by:
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Licensee shall provide written plan of action to show the steps they will take to prevent this issue from happening again. All staff training must be complete by POC date and copies of training materials along with sign-in sheet must be emailed to LPA
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Based on incident report and R1's record review the licensee did not comply with the section cited by allowing R1 with diagnosis of dementia to leave the facility without supervision, contrary to physician orders. This can pose a potential health and safety risks to residents in care.
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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.
Nichelle Gillyard
NAME OF LICENSING PROGRAM MANAGER:
Huma Rahimi
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/07/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/07/2026


LIC809 (FAS) - (06/04)
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