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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405800577
Report Date: 05/27/2026
Date Signed: 05/27/2026 06:09:30 PM

Document Has Been Signed on 05/27/2026 06:09 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:VILLAGE AT SYDNEY CREEK, THEFACILITY NUMBER:
405800577
ADMINISTRATOR/
DIRECTOR:		AUDIE SHERBERGFACILITY TYPE:
740
ADDRESS:1234 LAUREL LANETELEPHONE:
(805) 543-2350
CITY:SAN LUIS OBISPOSTATE: CAZIP CODE:
93401
CAPACITY: 84CENSUS: 48DATE:
05/27/2026
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Administrator - Audie SherbergTIME VISIT/
INSPECTION COMPLETED:
06:20 PM
NARRATIVE
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At 9:30am, on 5/27/2026, Licensing Program Analyst (LPA) Haner-Tomasko arrived at the facility unannounced to conduct a case management-other visit to the facility. LPA met with Administrator Audie Sherberg, announced who he was and the reason for the visit.

During today's visit LPA, Administrator, and Administrator in Training conducted a tour of the facility checking the overall safety and wellbeing of the residents in care.

During today’s visit LPA also delivered final findings to complaint control number 29-AS-20260504152017. The complaint included incident’s that occurred on 4/30/2026 and 5/3/2026 where Resident #1 (R1) accessed rodent poison from rodent bait stations located in the courtyard accessible to residents in care. On 4/3/2025, the staff who found R1 with the bait station open and touching the packets communicated the issue to the med-tech, who only advised R1 to wash their hands and be monitored. Shortly after, the med-tech and staff crossed paths with the facility nurse and communicated R1 had the bait station rock but did not communicate it was open or R1 had access to the packets. Additionally, none of this information was communicated to the Administrator until the second incident on 5/3/2026. Facility staff did not appropriately communicate important updates about R1 to facility management, who would have taken different actions had they been notified. R1 opening the bait stations posed a risk to not only themselves but also other residents.

(Continued on LIC809-C)
NAME OF LICENSING PROGRAM MANAGER: Kelly Burley
NAME OF LICENSING PROGRAM ANALYST: Garrett Haner-Tomasko
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/27/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/27/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 5
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 N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: VILLAGE AT SYDNEY CREEK, THE
FACILITY NUMBER: 405800577
VISIT DATE: 05/27/2026
NARRATIVE
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During the investigation LPA noted an incident documented in R1’s Notes/Incidents dated 2/13/2026 that states a med-tech was passing medications and they placed R1’s hearing aids on the dining room table next to R1. The med-tech briefly turned away to assist another resident. Upon turning back to R1 they noticed that one hearing aid was missing and R1 had the other hearing aid in one hand and a cup of water in the other. The med-tech could not find the hearing aid and staff felt R1 may have ingested it. Staff notified R1’s primary care physician (PCP) at the time of the incident, the PCP instructed staff on what to observe, and the PCP visited the resident later the same day.

Additionally, on 5/8/2026 the facility self-reported to Community Care Licensing (CCL) an incident that occurred on 5/7/2026 that staff observed Resident #2 (R2) exit another residents room when R2 complained to staff that they had a burning sensation in their mouth. Staff observed the corners of R2’s mouth to be red and a small amount of blood on their tongue. Staff assisted R2 to rinse out their mouth and when staff went to the room R2 was observed leaving they found an unattended hygiene cart. On the cart accessible to residents was Aveeno daily moisturizing lotion and Symmetry foaming hand sanitizer, Aveeno body wash, no-rinse hair & skin cleaning spray, Lubriderm lotion, and toothpaste. Staff called 911 and Poison Control. Emergency responders and Poison Control indicated R2 did not need to be seen at the hospital but instructed staff to monitor R2 for changes in condition and to call 911 should R2 experience changes in condition. This unattended hygiene cart was accessible to all residents in neighborhood #1 posing a threat.

During the tour conducted on todays visit LPA observed and photographed in unlocked cabinets in the kitchen area of neighborhoods #2 and #3 unlocked first aid kits with aspirin, ibuprofen, and other medications accessible to residents in care. Additionally in neighborhood #3 in a plastic three drawer bin on the kitchen counter two pairs of office scissors, antiperspirant spray, and spray body cleaner.

During the facilities annual inspection conducted on 6/18/2025 a citation was issued for hazardous and poisonous items being accessible to residents in care.

Although interviews revealed some efforts have been made to make hazardous and poisonous substances inaccessible to residents in care, there is a continued pattern of inadequate supervision and failure to consistently implement effective safeguards.
(Continued on LIC809-C)
NAME OF LICENSING PROGRAM MANAGER: Kelly Burley
NAME OF LICENSING PROGRAM ANALYST: Garrett Haner-Tomasko
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/27/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/27/2026
LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 05/27/2026 06:09 PM - It Cannot Be Edited


Created By: Garrett Haner-Tomasko On 05/27/2026 at 08:43 AM
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: VILLAGE AT SYDNEY CREEK, THE
FACILITY NUMBER: 405800577

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/27/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/12/2026
Section Cited
CCR
87309(a)

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(a)...the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances,... and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage. This requirement was not met as evidenced by:
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During today's visit staff removed hazardous items found during tour, the administrator purchased locking hygiene carts after the incident with R2, the bait stations were previously removed. Additionally Administrator states a maintenance director was hired 5/25/2026...
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Based on interview and record review, the licensee did not ensure hazardous and poisonous items were inaccessible to residents which poses an immediate health, safety, and personal rights risk to persons in care.
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who will conduct regular checks of the facility. The Administrator will also conduct staff training at their next all staff meeting scheduled for 6/10/2026 and will email LPA training documents and signed staff roster on or before 6/12/2026.

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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Kelly Burley
NAME OF LICENSING PROGRAM MANAGER:
Garrett Haner-Tomasko
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/27/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/27/2026


LIC809 (FAS) - (06/04)
Page: 4 of 5
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: VILLAGE AT SYDNEY CREEK, THE
FACILITY NUMBER: 405800577
VISIT DATE: 05/27/2026
NARRATIVE
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Exit interview, deficiency cited on LIC809-D page, a civil penalty of $250 for a repeat violation within twelve months is being assessed on the attached LIC421FC, report signed, report and appeal rights provided to the Administrator.
NAME OF LICENSING PROGRAM MANAGER: Kelly Burley
NAME OF LICENSING PROGRAM ANALYST: Garrett Haner-Tomasko
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/27/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/27/2026
LIC809 (FAS) - (06/04)
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