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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602362
Report Date: 08/23/2025
Date Signed: 08/23/2025 12:20:47 PM

Document Has Been Signed on 08/23/2025 12:20 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:HARRIET HOUSEFACILITY NUMBER:
198602362
ADMINISTRATOR/
DIRECTOR:		EASTON, ALYCEFACILITY TYPE:
735
ADDRESS:24 W HARRIETTELEPHONE:
(626) 794-4103
CITY:ALTADENASTATE: CAZIP CODE:
91001
CAPACITY: 12CENSUS: 6DATE:
08/23/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Gracie RinconTIME VISIT/
INSPECTION COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA) Tuesday Cabiness conducted an unannounced annual inspection. LPA attempted to enter the facility, but the gate was locked. LPA contacted the phone number in FAS and left a message with staff named Kim Commodore. Eventually, LPA reached someone at a different facility location, who contacted the facility at Harriet House. LPA was greeted by direct service provider (DSP) Gracie Rincon and informed her the reason of the visit. LPA entered the facility and observed (3) additional staff and (6) clients. Administrator Greg Tillman was contacted and informed LPA he will come to the facility. He arrived at 12pm.
A physical plant tour of the inside and outside of the first building was conducted with staff Gracie. The property has a second building located in the back, which was observed to have the same layout. The facility is fire cleared for twelve (12) ambulatory residents.

Kitchen: The kitchen was clean and the appliances and fixtures were functional. LPA found a sufficient amount of perishable and non-perishable food at the facility; and properly stored. The facility has an extra refrigerator stocked with food located in the second property. Chemicals and medication are stored in the property, which was locked and secured. Bedrooms: Building one, has (4) bedrooms for client's use. Two rooms are shared and there are (2) private. There is a staff office. All bedrooms were clean, neat, and properly furnished, with bedding and linens, as well as sufficient lighting. Bathroom: There are three bathrooms designated for client' use. All bathrooms were properly supplied with soap and towels, as well as functional fixtures; including grab bars. Hot water temperature 111.4 degrees Fahrenheit. Common Areas: Included the living room and dining area: all areas were clean and were properly furnished.

See LIC809C
NAME OF LICENSING PROGRAM MANAGER: Naira Margaryan
NAME OF LICENSING PROGRAM ANALYST: Tuesday Cabiness
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 08/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/23/2025
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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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: HARRIET HOUSE
FACILITY NUMBER: 198602362
VISIT DATE: 08/23/2025
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Grounds: Entry/exits were free of obstruction. The outdoor area was clean and free of hazards, with shaded furniture for clients. Smoke alarms were tested and operating properly. The fire extinguisher was fully charged. First aide had Licensing requirement items. Fire and earthquake drill was conducted 08/07/2025.

Client records. Clients record were reviewed for current IPP and/or Needs and Service plans; physician report, and admission agreements. Client records were current.

Staff records: All required documents in staff files. Training records were current and update.

Exit interview conducted and copy of report provided.

NAME OF LICENSING PROGRAM MANAGER: Naira Margaryan
NAME OF LICENSING PROGRAM ANALYST: Tuesday Cabiness
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2025
LIC809 (FAS) - (06/04)
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