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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610690
Report Date: 04/29/2025
Date Signed: 04/29/2025 03:19:33 PM

Document Has Been Signed on 04/29/2025 03:19 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:A&A CHEERFUL HEART HOMECAREFACILITY NUMBER:
197610690
ADMINISTRATOR/
DIRECTOR:		BALDEMOR, ALLANFACILITY TYPE:
735
ADDRESS:27580 CHERRY CREEK DRIVETELEPHONE:
(213) 235-8383
CITY:SANTA CLARITASTATE: CAZIP CODE:
91354
CAPACITY: 6CENSUS: 0DATE:
04/29/2025
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:55 PM
MET WITH:Allan Baldemor- AdministratorTIME VISIT/
INSPECTION COMPLETED:
03:40 PM
NARRATIVE
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On 4/29/2025, at approximately 1:00 PM, Licensing Program Analyst (LPA) Angelica Segovia conducted an announced Pre-licensing visit. LPA Segovia met with Administrator Allan Baldemor.

An application was submitted to Community Care Licensing Division-CCLD on 01/23/2025, Initial license for an Adult Residential Facilities (ARF). The requested capacity is for four (clients) of which two (2) can be ambulatory and two (2) non-ambulatory. The fire clearance was approved on 02/12/2025.

Structure: The facility is a single-story building with seven (7) bedrooms and two (2) bathrooms which include two (2) designated staff rooms and one (1) designated staff office.

Entrance: Upon entrance, required postings such as: Personal Rights Adult Residential Facilities, Rights of Resident by Council, Facility Sketch, and See Something Say Something were observed.

Common Areas: The living room and dining room were observed to be neat, clean, and organized with sufficient seating for both clients and staff. The rooms were observed to be properly furnished and in good repair. The facility maintains a comfortable temperature of seventy (70) degrees. No firearms were observed or will be maintained on the premises. LPA observed a working telephone located in the kitchen. LPA observed a fireplace to be covered and inaccessible to clients.

Client/staff files: The client and staff files will be kept in the staff office located aside the kitchen. Files will be kept in a locked cabinet inaccessible to clients. LPA observed a complete First-aid kit not limited to tweezers, bandages, digital thermometer, and scissors.

LIC809C-continued

NAME OF LICENSING PROGRAM MANAGER: Troy Agard
NAME OF LICENSING PROGRAM ANALYST: Angelica Segovia
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/29/2025
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 4
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: A&A CHEERFUL HEART HOMECARE
FACILITY NUMBER: 197610690
VISIT DATE: 04/29/2025
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Medications: The medication will be stored in two (2) cabinets located within the kitchen. LPA observed medication cabinets to be equipped with a lock to ensure medications will not be accessible to clients.

Kitchen: The kitchen was observed to be equipped with sufficient supplies of dishes, cups, and silverware located within the kitchen cabinets and drawers. The knives/sharps were observed to be stored in a kitchen drawer locked and inaccessible to the clients. The cleaning solutions and toxins will be kept in the laundry room locked and inaccessible to clients. Sufficient supply of food such as: canned goods, bottles of water, cereal were observed in kitchen pantry. The kitchen appliances were observed to be working and in proper condition.

Emergency: The Fire extinguisher was observed to be located near the kitchen and dated 9/10/2024.

Bedrooms: The bedrooms were observed to be properly furnished with bed, nightstand, applicable lighting, and seating. Window coverings are in good repair, not broken or damaged.

Bathroom: The bathrooms were observed to be in proper condition and LPA observed the bathrooms to be equipped with sufficient personal hygiene for each client upon arrival. Towels and washcloths will not be shared. Appropriate grab-rails and slip-resistant mats were observed and in proper condition.

Hallways: The hallway was observed to be properly lighted. LPA observed extra linens/covers stored within each clients’ closets.

Laundry: The laundry room was observed to be located within the hallway’s passageway leading towards the bedrooms. The dryer and washer were observed to be in good repair.

The Garage: LPA observed there to be no garage accessible within the facility nor apart of the facility sketch.

Office: LPA observed staff office to be kept locked and located aside the kitchen.

Water Temperature: The water temperature was measured in the bathrooms and observed to be within regulations.

LIC809C-continued

NAME OF LICENSING PROGRAM MANAGER: Troy Agard
NAME OF LICENSING PROGRAM ANALYST: Angelica Segovia
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2025
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: A&A CHEERFUL HEART HOMECARE
FACILITY NUMBER: 197610690
VISIT DATE: 04/29/2025
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Smoke detectors: The smoke detectors and carbon monoxide were observed to be working properly and were tested. LPA observed two (2) fire doors working and in proper condition.

Outside: The outside was observed to be clean, free of hazards, and properly furnished with sufficient seating. LPA observed a shaded area for clients.



Pool: LPA observed there to be no body of water located within the premises.

Administration: The facility had submitted an Emergency and Disaster Plan For Adult Community Care Facilities. The Component III Orientation ARF was shown/reviewed with the Administrator.

The facility was observed to be in compliance with Title 22 Regulations at the time of the visit. This report will be forwarded to the Centralized Application Bureau (CAB). You will be notified by the CAB Analyst when your license has been approved.

Exit interview conducted and copy of this report was provided to the Administrator.

NAME OF LICENSING PROGRAM MANAGER: Troy Agard
NAME OF LICENSING PROGRAM ANALYST: Angelica Segovia
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2025
LIC809 (FAS) - (06/04)
Page: 4 of 4