405800577-7-16-2026-29-AS-GHTO-DW33BV-20260716180659

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 405800577
Report Date: 07/16/2026
Date Signed: 07/16/2026 06:08:41 PM

Document Has Been Signed on 07/16/2026 06:08 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, THE		FACILITY NUMBER:	405800577
ADMINISTRATOR/ DIRECTOR:	AUDIE SHERBERG		FACILITY TYPE:	740
ADDRESS:	1234 LAUREL LANE		TELEPHONE:	(805) 543-2350
CITY:	SAN LUIS OBISPO	STATE: CA	ZIP CODE:	93401
CAPACITY: 84		CENSUS: 51	DATE:	07/16/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:45 AM
MET WITH:	Administrator - Audie Sherberg		TIME VISIT/ INSPECTION COMPLETED:	06:15 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	At 08:45am, on 07/16/2026, Licensing Program Analyst (LPA) Haner-Tomasko arrived at the facility unannounced to conduct the annual facility inspection. LPA met with Administrator Audie Sherberg, announced who he was and the reason for the visit. Administrator, Administrator in Training, Maintenance Technician, and LPA conducted a full tour of the facility. This is a single story facility. Upon entering the main entry there is a lobby accessible to the public and from the main lobby there is key coded approved egress door access to three units (neighborhoods). Neighborhood 1 and 2 connect via doors and a garden area. There is a life enrichment room in the middle of neighborhoods 1 & 2 used for activities, that is also licensed by Community Care Licensing (CCL) as an adult day program (ADP). Neighborhood 3 has its own entry point and patio space. There are a total of 44 resident bedrooms that can be designated single or dual occupancy, but never allow the facility to exceed a census of 84. Each resident bedroom has a private bathroom, there are also public bathrooms located in each neighborhood. Each neighborhood has a common space, dining area, kitchen for serving meals, and laundry space for urgent laundry needs. LPA noted the garden areas in each neighborhood have seating and shade, and are accessible freely to residents and visitors. Doors leading to the outdoor spaces in each neighborhood have approved egress devices that are activated in the evening for added resident safety and deactivated during the day for free access. The lobby contains seating and a self contained fireplace. LPA noted a carbon monoxide detector located next to the fireplace that is working. The west side of the lobby leads to a concierge desk, administrative offices, public restrooms and a snack bar. There are also two conference rooms. (Continued on LIC809-C)

NAME OF LICENSING PROGRAM MANAGER: Kelly Burley
NAME OF LICENSING PROGRAM ANALYST: Garrett Haner-Tomasko
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 07/16/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2026

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

FACILITY NAME: VILLAGE AT SYDNEY CREEK, THE	FACILITY NUMBER: 405800577
	VISIT DATE: 07/16/2026

NARRATIVE

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The hallway leading away from the lobby toward neighborhood 3 gives access to the main kitchen where all meals are prepared and delivered to the neighborhoods, the medication room, a salon, a wellness center, the main laundry room, staff break room and two additional public bathrooms. Residents do not have access to these areas independently. LPA noted that the facility has no obstructions in hallways, doorways or exits.

The facility has wired smoke detectors in each resident room and hallway leading to resident rooms that were tested by Alpha Fire and Alarm on 2/20/2026 and the sprinkler system was tested on the same day by the same company. LPA observed fire extinguishers throughout the facility in the green compression range, scheduled to be serviced tomorrow, 7/17/2026. LPA noted an emergency chair in neighborhood 3 should the facility need to evacuate down stairs located through this neighborhood's courtyard that lead to a side street. LPA tested facility hot water at various resident faucets throughout the facility ranging from 102.9 - 115°F. LPA noted the facility takes daily temperature checks of the hot water at various rooms and is continuing to work with outside companies to correct the hot water temperature, LPA provided ongoing technical assistance for the water temperature issue.

While touring the main kitchen LPA observed at least 2-days of perishable and at least 7-days of nonperishable foods. The main kitchen faucets are not accessible to residents and deliver hot water above 125°F and are clearly marked.

LPA conducted a sample medication audit and reviewed the facilities Centrally Stored Medication Records. LPA conducted a staff and resident file review.

LPA and Administrator conducted a review of the annual care tool modules. There were no deficiencies cited at this time.

Exit interview conducted, report signed, and report provided to the Administrator.

NAME OF LICENSING PROGRAM MANAGER: Kelly Burley
NAME OF LICENSING PROGRAM ANALYST: Garrett Haner-Tomasko
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 07/16/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2026

LIC809 (FAS) - (06/04)

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