198600312-5-8-2026-31-AS-NSHN-DTVSZV-20260508141947

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198600312
Report Date: 05/08/2026
Date Signed: 05/08/2026 02:20:00 PM

Document Has Been Signed on 05/08/2026 02:20 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:	KOCH-VAGTHOL'S METABOLIC RESIDENTIAL CENTER		FACILITY NUMBER:	198600312
ADMINISTRATOR/ DIRECTOR:	JANE BUNAG		FACILITY TYPE:	735
ADDRESS:	753 SOUTH MARIPOSA STREET		TELEPHONE:	(818) 843-2695
CITY:	BURBANK	STATE: CA	ZIP CODE:	91506
CAPACITY: 5		CENSUS: 5	DATE:	05/08/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:30 AM
MET WITH:	Jane Bunag - Administrator		TIME VISIT/ INSPECTION COMPLETED:	02:30 PM

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An unannounced Required One (1) year visit was conducted on this day by Licensing Program Analyst (LPA) Nadia Shahbazian. Upon arrival LPA was greeted by Emmeline Baldoza-Lead DSP, and advised the reason for the visit. The Administrator-Jane Bunag, arrived around 10:10am. This is a Level VII Specialized Lanterman Regional Center vendored facility. The Adult Residential Facility (ARF) is licensed to care for five (5) Developmentally Disabled Non-Ambulatory Adults, ages 18 through 59. Facility was granted exceptions by Community Care Licensing (CCL) for two (2) clients over the age of 59.

LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today. At 11:15am LPA conducted the facility tour and observed the following: Required postings were observed in the hallway.

The facility is a one story building, located next to Vagthol’s Residential Care Center #2 - RCFE (751 S Mariposa Street, Burbank CA 91506). There is a wall in between both facilities, with a small access between both. The administration building for both facilities is located behind the Koch-Vagthol’s Metabolic Residential Center and is accessible by both facilities. There are three car ports in the back, shared by both facilities but there is no garage. There are storage rooms next to the administration office. There is an enclosed patio area with furniture appropriate for outdoor use. There are no bodies of water present.

There are fire sprinklers and smoke/carbon monoxide detectors throughout the facility. At 9:22am smoke/carbon monoxide detectors were tested and observed to function properly. There are auditory alarms on all exit doors and LPA tested every door to ensure the alarms were functional. There are four fire extinguishers, one located in the kitchen one in the laundry room, one in the back storage and one in the administration office. All fire extinguishers were fully charged and were serviced on 10/20/2025. Facility conducts monthly fire drills and quarterly earthquake/safety drills. The last fire drill was conducted on 04/06/2026 and the earthquake drill was conducted on 04/21/2026.

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NAME OF LICENSING PROGRAM MANAGER: Mary G Flores
NAME OF LICENSING PROGRAM ANALYST: Nadia Shahbazian
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/08/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2026

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: KOCH-VAGTHOL'S METABOLIC RESIDENTIAL CENTER	FACILITY NUMBER: 198600312
	VISIT DATE: 05/08/2026

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Common Areas: There living room is located by the entry door, which leads to the dining room. Another activity/family room is located next to the dining room. All common area rooms were properly furnished with couches, recliners, massage chair, tables and chairs, appropriate for number of clients and staff. Television set is located in the living room and activity/gaming cabinet was observed in the dining room. There is a small office area located on the corner of the dining room and there is a staff lounge in the hallway. There are exit doors in each clients’ bedrooms and two exits in the dining room and the activity/family room, clearly marked with exit signs. Facility utilizes the dining room and the activity/family room exits as the main emergency exits.

Kitchen: The kitchen appliances and fixtures were functional and clean. LPA found a sufficient amount of perishable (2 days) and non-perishable food (7 days) at the facility. All food supplies were properly labeled with purchase dates. Knives/sharp objects were stored in a locked cabinet and chemicals were locked underneath the sink.

Bathrooms: There are two (2) bathrooms designated for clients’ and one (1) for staff use. All toilets and sinks are maintained in sanitary, operating condition. LPA observed proper grab bars and non-skid mats in client bathrooms. Hot water temperature in client bathrooms were measured at 113.5 and 115.7 degrees Fahrenheit.

Bedrooms: There are a total of seven (7) bedrooms in the home. There are five (5) private bedrooms for client use and two (2) bedrooms for staff but there is always awake staff during each shift. The bedrooms were observed to be properly furnished with appropriate beddings, chairs, dresser drawers and linens with sufficient lighting. All bedrooms, except for one of the staff bedrooms have exit doors.

Laundry Room: The laundry room is located in the hallway. A washer, dryer and cabinets to store linens and toiletry were observed. A locked cabinet is used to store detergents and chemicals.

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NAME OF LICENSING PROGRAM MANAGER: Mary G Flores
NAME OF LICENSING PROGRAM ANALYST: Nadia Shahbazian
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/08/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2026

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: KOCH-VAGTHOL'S METABOLIC RESIDENTIAL CENTER	FACILITY NUMBER: 198600312
	VISIT DATE: 05/08/2026

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Client Files: LPA conducted a file review of resident records for all five clients to ensure compliance of licensing forms. P&I for all five clients were counted and compared to purchase receipts.

Staff Files: LPA also conducted a file review of staff records to ensure forms and training are up to date and are in compliance with licensing forms.

Medications: All medications, the first-aid kit and the first aid manual were kept locked in a kitchen cabinet. Medications were counted for all five clients for accuracy of administration and were compared to Medication Administration Records (MAR)s.

Operational Requirements: Facility has a transportation van with valid car insurance through 09/15/2026. Surety Bond in the amount of $10,000 is in effect since 12/02/2025. Facility Certificate of Liability Insurance has an expiration date of 12/22/2026. Administrative Certificate has expiration date of 05/23/2028.

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

Exit Interview Conducted and a Copy of the Report provided to the Administrator.

NAME OF LICENSING PROGRAM MANAGER: Mary G Flores
NAME OF LICENSING PROGRAM ANALYST: Nadia Shahbazian
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/08/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2026

LIC809 (FAS) - (06/04)

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