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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610639
Report Date: 09/05/2025
Date Signed: 09/05/2025 04:16:20 PM

Document Has Been Signed on 09/05/2025 04:16 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:VAGTHOL'S RESIDENTIAL CARE CENTER #3FACILITY NUMBER:
197610639
ADMINISTRATOR/
DIRECTOR:		FRANCISCA CHAMUFACILITY TYPE:
735
ADDRESS:2301 SCOTT RD.TELEPHONE:
(323) 788-9924
CITY:BURBANKSTATE: CAZIP CODE:
91504
CAPACITY: 6CENSUS: 6DATE:
09/05/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Francisca Chamu-AdministratorTIME VISIT/
INSPECTION COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) Nadia Shahbazian conducted an unannounced Required - 1 Year annual inspection visit. LPA met with Francisca Chamu-Administrator and explained the purpose of the visit. The program is vendorized through the Frank D. Lanterman Regional Center. The Adult Residential Facility is licensed for 6 non-ambulatory adults, ages 18 through 59. Current census is six (6) residents.

LPA toured the facility with the Administrator at 10:30 am and observed the following:



Required postings were observed in the hallway. The front entry is the main exit door and the secondary exit door is located in the hallway, leading to the backyard. Each of the bedrooms also have exit doors with alarms on each door. All the exit doors are clearly marked with "Exit signs" above the doors. There are four fire extinguishers, one across the entry door, one in the hallway, one in the basement and one in the Accessory Dwelling Unit (ADU). All four fire extinguishers are fully charged on 05/16/2025. Facility conducts monthly fire and safety drills, and quarterly earthquake drills. The last fire and earthquake drill was conducted together on 08/04/2025. The smoke and carbon monoxide detectors are battery operated.
At 11:11 am the smoke/carbon monoxide detectors were tested and observed to function properly.

Kitchen: The kitchen appliances consisted of a refrigerator, stove, dishwasher and microwave and the fixtures were observed to be functional. Knives, cutlery and sharp kitchen objects are stored in locked in medicine cabinet, in the hallway next to the kitchen. The cleaning supplies were also locked in cabinet underneath the sink. LPAs found a sufficient supply of perishable foods (2 days) and non-perishable food
(7 days) supplies, with sufficient amount of dishes. All kitchen surfaces and cabinets were observed to be clean and sanitary.

Continued on 809-C
NAME OF LICENSING PROGRAM MANAGER: Eva Miller
NAME OF LICENSING PROGRAM ANALYST: Nadia Shahbazian
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/05/2025
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: VAGTHOL'S RESIDENTIAL CARE CENTER #3
FACILITY NUMBER: 197610639
VISIT DATE: 09/05/2025
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Common Areas: Include living room and a dining room. The common areas were properly furnished with ample sitting/tables for appropriate number of clients. A screened fireplace, a television set and cabinets with activity/gaming areas were observed in the living room.

Bathrooms: There are two (2) bathrooms designated for residents and one bathroom (near the staff lounge/office) designated for staff use. All toilets and sinks are maintained in sanitary, operating condition. LPA observed proper grab bars and non-skid mats in both bathrooms. Hot water temperature in resident bathrooms were measured at 106.1 and 108.0 degrees Fahrenheit.

Bedrooms: There are six (6) private bedrooms designated for clients' use. All the bedrooms have exit doors with clearly marked "exit signs" above each door and with alarm chimes. All of the bedrooms were properly furnished with appropriate chairs, beddings. television sets, linens with sufficient lighting.

Basement: There is a door from the hallway, leading to a locked basement. LPA observed a waterheater and a storage room in the basement, along with cabinets used to store supplies.

Storage areas: Facility has a pantry in the hallway for additional food supplies. In addition, multiple storage closets were observed in the hallway, supplied with linens and personal hygiene items.



Surrounding grounds: The entrance to the home is gated. There is a water fountain at the front yard, with tables and chairs and a covered porch with sitting area. LPA observed appropriate outdoor furniture, gardening flower beds, a covered shaded area and a locked storage shed in the backyard. Facility has an electrical generator in the backyard. Entry/exit gates and pathways were free of obstruction and free of visible immediate hazards. Facility has no garage; the detached garage was converted into a permitted ADU. The ADU consists of two bedrooms, one bathroom, a kitchen, living/dining room area and is currently used a staff lounge only. The laundry room is located near the ADU. LPA observed a washing machine and dryer and locked cabinets for detergents/chemicals in the laundry room.

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NAME OF LICENSING PROGRAM MANAGER: Eva Miller
NAME OF LICENSING PROGRAM ANALYST: Nadia Shahbazian
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/05/2025
LIC809 (FAS) - (06/04)
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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: VAGTHOL'S RESIDENTIAL CARE CENTER #3
FACILITY NUMBER: 197610639
VISIT DATE: 09/05/2025
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First-Aid Kit/Medications: All medications were observed to be locked in a hallway cabinet, near the kitchen. In the same cabinet, LPA observed several complete first-aid kits with all required supplies and the first aid manual.

Resident Files/Medications: A review of resident records to ensure compliance of licensing forms was conducted. Medications records for residents were also verified for accuracy of administration based on physician orders. LPA counted medications for 6 out of 6 residents to ensure accuracy of administration vs. physician's orders.



Staff Files: Staff files were reviewed to ensure all forms and training certificates are up to date.

Pursuant to Title 22 Division 6 of the CA Code of Regulations, no deficiencies observed during the visit.

Exit Interview Conducted / A Copy of the Report provided to Administrator.

NAME OF LICENSING PROGRAM MANAGER: Eva Miller
NAME OF LICENSING PROGRAM ANALYST: Nadia Shahbazian
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/05/2025
LIC809 (FAS) - (06/04)
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