198601809-9-23-2025-29-AS-QHUH-DLSRJ2-20250923130314

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198601809
Report Date: 09/23/2025
Date Signed: 09/23/2025 01:03:38 PM

Document Has Been Signed on 09/23/2025 01:03 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 N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	ELWYN NC - BABCOCK		FACILITY NUMBER:	198601809
ADMINISTRATOR/ DIRECTOR:	HAZEL LAZAGA GATAN		FACILITY TYPE:	734
ADDRESS:	5149 BABCOCK AVE		TELEPHONE:	(818) 287-5416
CITY:	VALLEY VILLAGE	STATE: CA	ZIP CODE:	91607
CAPACITY: 5		CENSUS: 3	DATE:	09/23/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:26 AM
MET WITH:	Laurie Hernandez - Administrator		TIME VISIT/ INSPECTION COMPLETED:	01:10 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Quoc Huynh and North Los Angeles Regional Center (NLARC) Quality Assurance Specialist (QA) Lisseth Carrillo arrived at the facility unannounced to conduct a required annual inspection. The LPA and QA arrived at the facility at 9:26AM, met with Staff Danny Lopez and explained the purpose of the visit. At 11:59AM, Administrator Laurie Hernandez arrived. Entrance interview conducted. LPA Huynh and the Staff conducted a tour of the physical plant at 9:45AM to ensure there were no health and safety hazards, and the facility is in compliance with Title 22 Regulations. The following was observed: KITCHEN: Knives were stored inaccessible in a drawer near the stove. Kitchen appliances were in good and operable condition. The facility had enough supply of perishable and non-perishable food. The freezer and refrigerator were stocked with a variety of foods and observed to be of good quality with labels and dates. COMMON AREAS: At the time of the visit, the living room and dining room furniture was observed to be in good condition. An office area was located within the dining room and had required postings along the wall. There was a second living room located at the entrance of the facility with two (2) closets nearby that contained medical supplies. There was a locked laundry room in the hallway with machines in good condition and cabinets that stored general supplies and cleaning supplies. The facility maintained a comfortable temperature throughout the visit. Report Continued on LIC 809-C

NAME OF LICENSING PROGRAM MANAGER: Kristin Heffernan
NAME OF LICENSING PROGRAM ANALYST: Quoc Huynh
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 09/23/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2025

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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Document Has Been Signed on 09/23/2025 01:03 PM - It Cannot Be Edited

Created By: Quoc Huynh On 09/23/2025 at 12:40 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: ELWYN NC - BABCOCK	FACILITY NUMBER: 198601809
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/23/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

80020(a)

Fire Clearance

(a) All facilities shall secure and maintain a fire clearance approved by the city or county fire department, the district providing fire protection services, or the State Fire Marshal. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in the fire doors were not operational which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 09/24/2025
	Plan of Correction
1 2 3 4	The Licensee/Administrator contacted the property management company and requested a technician to inspect the fire doors and will send CCLD proof of the operating fire doors by the POC due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Kristin Heffernan
NAME OF LICENSING PROGRAM MANAGER:

	Quoc Huynh
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/23/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 09/23/2025 01:03 PM - It Cannot Be Edited

Created By: Quoc Huynh On 09/23/2025 at 12:40 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: ELWYN NC - BABCOCK	FACILITY NUMBER: 198601809
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/23/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80069(b)

Clients Medical Assessments

(b) In ARFs, prior to accepting a client into care, the licensee shall obtain and keep on file documentation of the client's medical assessment. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview and record review, the licensee did not comply with the section cited above 2 out of 3 clients did not have a Physician's Report which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/07/2025
	Plan of Correction
1 2 3 4	The Licensee/Administrator will obtain 2 clients' Physician's Report and send to CCLD by POC due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Kristin Heffernan
NAME OF LICENSING PROGRAM MANAGER:

	Quoc Huynh
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/23/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2025

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 N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: ELWYN NC - BABCOCK	FACILITY NUMBER: 198601809
	VISIT DATE: 09/23/2025

NARRATIVE

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BEDROOMS/RESTROOMS: The facility had five (5) bedrooms, each private. Bedrooms were furnished appropriately with sufficient lighting and an extra supply of bed linens stored in each bedroom. There were two (2) restrooms: one (1) shared resident restroom and one (1) staff/guest restroom. The resident restroom was observed to be clean and in good condition with grab bars and non-skid mats available. A sufficient amount of soap and paper products were supplied in each restroom and hand washing signs were posted. Hot water was tested and measured at 111.6 degrees F, which is within the required range.

OUTDOOR AREA: The facility had a detached garage in the rear of the property. The garage contained emergency food and water, general storage, cleaning supplies, and extra medical supplies. The rear yard had a covered patio equipped with outdoor furniture in good condition for clients’ use in addition to a grill. There were two (2) emergency exits: one (1) side gate and one (1) driveway. Passageways were unobstructed and remained clear.

RECORDS: Record review began at 10:05AM. Client records were reviewed for, but not limited to, care plans, medical records, admissions agreement, and consent forms. Client #1 (C1) did not have a current Physician’s Report and C1’s Physician’s Report from the prior year was signed by a Physician but not completed. The Administrator stated they recalled C1 had a completed assessment the prior year and that their current assessment was completed on 08/21/2025 and emailed to Kaiser to fill out. Client #2 (C2) did not have a Physician’s Report and arrived at the facility on 08/21/2025. The Administrator and House Manager stated C2 has an appointment on 09/30/2025 to complete their Physician’s Report. Personnel records were reviewed for, but not limited to health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All files were in order.

Report Continued on LIC 809-C

NAME OF LICENSING PROGRAM MANAGER: Kristin Heffernan
NAME OF LICENSING PROGRAM ANALYST: Quoc Huynh
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 09/23/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2025

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 N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: ELWYN NC - BABCOCK	FACILITY NUMBER: 198601809
	VISIT DATE: 09/23/2025

NARRATIVE

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INFECTION CONTROL/EMERGENCY DISASTER PLAN: During today’s visit, LPA reviewed the facility’s infection control plan and emergency disaster plan. Both documents were observed to be complete and reviewed annually. Emergency disaster drills are conducted monthly, with the last drill documented on 09/02/2025. Fire extinguishers were fully charged and last serviced on 03/17/2025. Smoke and carbon monoxide detectors were tested at 11:52AM and were operational, however did not trigger the magnetic fire doors.

An immediate civil penalty of $500 for a violation of the facility’s fire clearance was issued (Refer to LIC 412M). The Licensee/Administrator understands that continued violation of the facility’s fire clearance may result in additional civil penalties.

Pursuant to Title 22 CA Code of Regulations and/or the Health and Safety Code, the following deficiencies were cited (Refer to LIC 809-D).

The LPA will return at a later date to conduct the medication review.

Exit interview conducted. A copy of the Appeal Rights and report was reviewed and provided.

NAME OF LICENSING PROGRAM MANAGER: Kristin Heffernan
NAME OF LICENSING PROGRAM ANALYST: Quoc Huynh
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 09/23/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2025

LIC809 (FAS) - (06/04)

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