197611005-5-18-2026-31-AS-TCAS-DU7P8X-20260518110617

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197611005
Report Date: 05/18/2026
Date Signed: 05/18/2026 11:07:32 AM

Document Has Been Signed on 05/18/2026 11:07 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:	CHERISHED MOMENTS LIVING		FACILITY NUMBER:	197611005
ADMINISTRATOR/ DIRECTOR:	ACOBIANCE, CHRISTINA		FACILITY TYPE:	740
ADDRESS:	28125 BAKERTON AVENUE		TELEPHONE:	(818) 445-9195
CITY:	CANYON COUNTRY	STATE: CA	ZIP CODE:	91351
CAPACITY: 6		CENSUS: 0	DATE:	05/18/2026
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:15 AM
MET WITH:	Christina & Marina Acobiance		TIME VISIT/ INSPECTION COMPLETED:	11:20 AM

NARRATIVE

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Licensing Program Analyst (LPA) Tuesday Cabiness conducted a PRE-LICENSING visit to the above address 28125 Bakerton Ave, Canyon County, CA, 91351. LPA met with Administrator Christina Acobiance and Licensee Marina Acobiance. The inspection included, fire safety, personal accommodations, building and grounds, furniture/equipment, and food service. Fire Inspection was approved on March 06, 2026 which met fire department requirements for (2) shared rooms, and (2) private rooms, which all rooms could have non-ambulatory residents; room # 4, is only allowed for (1) bedridden resident, which includes an exit door. Facility has approval for (6) hospice residents. Facility sketch, emergency disaster plan, complaint procedures, personal rights, emergency exit plan, and other required Licensing posting were visible on the wall.

The physical plant was toured inside and out with Administrator and Licensee. The facility is a one level home, with (4) bedrooms and (2) bathrooms; there is no staff room or office. Kitchen was inspected and observed, and storage areas, cabinets, pantries, cupboards counters, and refrigerator were clean and appropriate for food preparation. Knives and medication were stored in cabinets located in the kitchen area. Appliances were clean and functional, and utensils, plates, and cups were in good repair. Cleaning supplies, poisons, toxins and chemicals were locked and stored in the laundry room, located in the garage. There was enough supply of linens and towels.

The common areas included the dining, living, bathroom, and bedrooms. Doors and passageways were clear and unobstructed. Walls, ceilings, floors, window screens and all other rooms were clean, in good repair, and appropriately furnished. Resident rooms observed to have a mattress with pad, sheets, pillow, bedspread, dresser, closet space, and chair. Bathrooms were clean had functional fixtures, with soap and towels, non-skid mats, and grab bars. The water temperature measured at 105.8 degrees Fahrenheit. The back yard is completely fenced with (2) gates easily accessible and unlocked. (Cont'd LIC809C)

NAME OF LICENSING PROGRAM MANAGER: Nichelle Gillyard
NAME OF LICENSING PROGRAM ANALYST: Tuesday Cabiness
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/18/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2026

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: CHERISHED MOMENTS LIVING	FACILITY NUMBER: 197611005
	VISIT DATE: 05/18/2026

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There are no swimming pools or other bodies of water, no visible hazards around the surrounding grounds. Patio furniture observed for resident's use. Smoke detectors and carbon monoxide were hardwired and operating correctly. Fire extinguisher is fully charged. Telephone installation was completed. First aid kit inspected. Staff and client files will be stored in locked cabinet, located in the dining room area.

COMP III was completed during the visit.

Exit interview conducted and copy of report provided to Administrator.

NAME OF LICENSING PROGRAM MANAGER: Nichelle Gillyard
NAME OF LICENSING PROGRAM ANALYST: Tuesday Cabiness
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/18/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2026

LIC809 (FAS) - (06/04)

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