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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197690036
Report Date: 06/04/2025
Date Signed: 06/04/2025 04:58:32 PM

Document Has Been Signed on 06/04/2025 04:58 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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:ELEVATIONSFACILITY NUMBER:
197690036
ADMINISTRATOR/
DIRECTOR:		CHEROKEE WATKINSFACILITY TYPE:
772
ADDRESS:3836 KANAN ROADTELEPHONE:
(858) 695-4069
CITY:AGOURA HILLSSTATE: CAZIP CODE:
91301
CAPACITY: 6CENSUS: 5DATE:
06/04/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:30 AM
MET WITH:Ama Reyes, Program Director & Greg AllenTIME VISIT/
INSPECTION COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) Zabel Chochian arrived at the facility unannounced to conduct a required annual visit. The LPA was greeted by staff Alexis Munoz. Director was contacted and arrived shortly after.

The LPA along with the staff toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. This is a two-story house. The following was observed. The LPA observed required postings throughout the common spaces.

BEDROOMS/BATHROOMS: The LPA began the inspection with the downstairs bedrooms and bathrooms. Bedrooms were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. There are six designated client rooms. There is a linen closet in the upstairs hallway with extra towels and linens. The client bathrooms were clean and sanitary and in operating condition. The bathrooms were sufficiently stocked with soap and paper towels. LPA measured hot water temperature in the clients bathroom on the first floor and upstairs. The hot water temperature was not within the required limit of 105-120 degrees Fahrenheit. Staff immediately adjusted the hot water temperature. First floor client bathroom measured at 125*F and the upstairs client bathroom hot water measured at 130*F.

KITCHEN: The LPA inspected the kitchen/food service area. Knives and cleaning supplies are stored inaccessible to clients. Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. Additional food supplies and emergency food supply are kept in the attached garage. COMMON AREAS: Multiple living rooms and dining furniture was observed to be in good condition. The facility maintained a comfortable temperature. There is a laundry room with washer and dryer; supplies all locked up. Office room located near the laundry area which leads into the attached garage are with keypad entry. Cleaning supplies, disinfectants and contraband items are kept locked. (Continue)

NAME OF LICENSING PROGRAM MANAGER: Desaree Perera
NAME OF LICENSING PROGRAM ANALYST: Zabel Chochian
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 06/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/04/2025
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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: ELEVATIONS
FACILITY NUMBER: 197690036
VISIT DATE: 06/04/2025
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OUTDOOR AREA: The backyard has a covered outdoor area equipped with furniture for client use. There is a side gate for client use and is single latched. A tennis court and pool observed on the premises. Pool observed to be covered and inaccessible, exits observed free of obstructions.

RECORDS: Clients’ records review began at 11:30 a.m., records were reviewed for, but not limited to care plans, medical records, admissions agreement, consent forms. LPA observed that four (4) out of four (4) clients records were complete. Medication records were reviewed at approximately 12:30pm.

At approximately 1:15p.m., personnel records were reviewed for, but not limited to health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All personnel records are electronically updated in Kipu EMR system. Three (3) out three (3) staff files reviewed observed complete with all required records.

Smoke detector(s) and carbon monoxide detector were tested at 2:15pm and were operational at the time of the visit. The fire extinguishers observed were fully charged and were last serviced 10/17/2024.

The LPA requested the following documents to be emailed to the Regional Office during todays visit: LIC500 Personnel Report, and Liability Insurance.



The following deficiencies were observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code.

Exit interview was conducted. A copy of the report and appeal rights were provided.
NAME OF LICENSING PROGRAM MANAGER: Desaree Perera
NAME OF LICENSING PROGRAM ANALYST: Zabel Chochian
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/04/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/04/2025 04:58 PM - It Cannot Be Edited


Created By: Zabel Chochian On 06/04/2025 at 03:16 PM
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. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: ELEVATIONS
FACILITY NUMBER: 197690036

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/04/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
81088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. Hot water temperature tested at approximately 125*f in the restroom used by clients located on the first floor in the hallway and 130*f in the upstairs client restroom (master room/bathroom). This poses/posed a potential safety risk to persons in care.
POC Due Date: 06/11/2025
Plan of Correction
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Licensee/representative agreed to have staff check all restroom hot water temperature twice day for one week to insure hot water temperature is within required range (105-120*f). Submit the one week log to LPA by POC due date.
Type B
Section Cited
CCR
81075(k)(7)
Health-Related Services
(k) The following requirements shall apply to medications which are centrally stored: (7) The licensee shall ensure the maintenance, for each client, of a record of centrally stored prescription medications which is retained for at least one year and includes the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above. Four out of five client medications and medication records reviewed were not properly documented with all of clients medication on hand in the Centrally Stored Medications Log. This poses an potential health and safety risk to persons in care.
POC Due Date: 06/11/2025
Plan of Correction
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The Licensee/representative agreed to the following:
1. Have staff document medications with all identifying information for all clients on the centrally stored medications log. Provide copy of the centrally stored medication logs to LPA by POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Desaree Perera
NAME OF LICENSING PROGRAM MANAGER:
Zabel Chochian
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/04/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/04/2025


LIC809 (FAS) - (06/04)
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