<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405801741
Report Date: 03/12/2025
Date Signed: 03/12/2025 04:54:17 PM

Document Has Been Signed on 03/12/2025 04:54 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:CHERISH HOUSE RETREAT, INC.FACILITY NUMBER:
405801741
ADMINISTRATOR/
DIRECTOR:		VIKKI HANSENFACILITY TYPE:
740
ADDRESS:1405 BERWICK DRIVETELEPHONE:
(805) 924-1462
CITY:CAMBRIASTATE: CAZIP CODE:
93428
CAPACITY: 8CENSUS: 8DATE:
03/12/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:40 AM
MET WITH:Backup Administrator - Michelle LathamTIME VISIT/
INSPECTION COMPLETED:
05:05 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
On 3/12/2025 at 09:40am, Licensing Program Analysts (LPA) Haner-Tomasko and De Leon arrived to conducted a one year annual visit to the facility above. LPA met with Backup Administrator Michelle Latham and explained the purpose of the visit.

A tour of the inside and outside of the facility was conducted. The following was inspected and noted during the annual visit:

Physical Plant & Environment Safety: The facility is a 6 bedroom and 4-bathroom home currently occupying 8 resident, employs 5 staff and 2 Administrators. One common area restroom, a jack and jill style restroom between two of the bedrooms and 2 private in suite bathrooms. The kitchen is clean, safe and sanitary. Toilet, hand washing and bathing facilities are operational and secured grab bars are present. The showers have non-skid mats. The pathways are clear of any obstructions. The facility has smoke and carbon monoxide detectors. Facility is well lit inside and outside for safety. The lighting and lamps are sufficient for the use of the facility and for resident comfort. The facility has sufficient space inside and outside for activities and visiting. The facility has a fenced backyard for resident use with plenty of shade. The facility has telephone and internet service for resident use.

Activities: During the visit LPA observed residents actively involved in facility activities (singing, watching TV, exercising, art). A musician played a flute for the residents. An activity calendar is displayed in the great room.

(Continued LIC809-C)
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Garrett Haner-Tomasko
LICENSING EVALUATOR SIGNATURE: DATE: 03/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/12/2025
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 10
Document Has Been Signed on 03/12/2025 04:54 PM - It Cannot Be Edited


Created By: Garrett Haner-Tomasko On 03/12/2025 at 03:45 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: CHERISH HOUSE RETREAT, INC.
FACILITY NUMBER: 405801741

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/12/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87307(e)(1)(A)
Personal Accommodations and Services
(e) The licensee shall supervise residents as needed and as determined by the resident's appraisal pursuant to Section 87457, Pre-Admission Appraisal or Section 87463, Reappraisals, when residents are in proximity to or when there is use of the following items: (1) Ranges, ovens, heaters, fireplaces, wood stoves, inserts, and other heating devices. (A) Heating devices shall have protective mechanisms or other measures to prevent access to the device, or to make it inoperable when not in use, in order to reduce the risk of burns or fire.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA observation, the licensee did not comply with the section cited above in resident's room 5 when a wall heater within reach of residents was hot to the touch which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/19/2025
Plan of Correction
1
2
3
4
Administrator agreed to have maintenance come out and install a guard/cover to protect residents from burns. Administrator will email LPA photos of cover.
Type B
Section Cited
CCR
87309(a)(1)
Storage Space and Access
(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, 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. (1) Disinfectants, cleaning solutions, and poisonous substances shall be stored in areas separate from food supplies as specified in Section 87555, General Food Service Requirements.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation chemicals and medications were left unlocked for residents at risk to gain accessto, the licensee did not comply with the section cited above in resident room 5 which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/19/2025
Plan of Correction
1
2
3
4
Administrator removed items immediatly and agreed to purchase and install new locking devices for cabinets to contain these items. Administrator will email LPA photos of new locking devices.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Kelly Burley
LICENSING EVALUATOR NAME:Garrett Haner-Tomasko
LICENSING EVALUATOR SIGNATURE:
DATE: 03/12/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/12/2025


LIC809 (FAS) - (06/04)
Page: 2 of 10
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: CHERISH HOUSE RETREAT, INC.
FACILITY NUMBER: 405801741
VISIT DATE: 03/12/2025
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
26
27
28
29
30
31
32
Infection Control: The facility has a current Infection Control Plan. The facility has a sign in and out binders for visitors at entry with hand sanitizer. The bathrooms have toilet paper, paper towels, hand soap, and hand washing signs. The facility has EPA approved disinfectants spray and cleaners. All trash cans and wastebaskets have tight fitting covers.

Operational Requirements: The facility has a current plan of operation on file with the department. The Facility is operating in compliance with the granted fire clearance. The facility has current liability insurance and expires on 07/17/2025. The facility is approved for a capacity of 8. The fire clearance is granted for 8 Non-Ambulatory of which 4 may be bedridden. Hospice is approved for 4.

Staffing: Staff records are kept confidential. Files reviewed had current 1st Aid/CPR, Personnel Records/Application, Health screening, and fingerprint clearance/Associations/exemptions. Administrator Certificate expires 09/30/2026.

Personnel Records & Training: Facility keeps records confidentially. Fire and Disaster drills are conducted quarterly. Facility staff have current First Aid and CPR training with valid certificates.

Resident Records & Incident Reports: The facility keeps separate files on each resident confidentially. LPAs reviewed resident file for signed Admission Agreements, Personal Rights, Safeguard for property and valuables, LIC. 602A Physicians report, Pre-appraisals, Emergency and ID forms, all forms were legible, and records are kept confidential.

Food Service: LPA observed 2-days perishables and 7-days non-perishables to meet the food service requirement. All food is covered, stored and marked appropriately. Food, snacks and drinks are available when the residents want them. Emergency supply of food and water is available. Cleaning solutions and equipment are stored separately from food supplies.

(Continued LIC809-C)
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Garrett Haner-Tomasko
LICENSING EVALUATOR SIGNATURE:

DATE: 03/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2025
LIC809 (FAS) - (06/04)
Page: 8 of 10
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: CHERISH HOUSE RETREAT, INC.
FACILITY NUMBER: 405801741
VISIT DATE: 03/12/2025
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
26
27
28
29
30
31
32
Incidental Medical Services: Facility provides transportation or assist in providing transportation to medical and dental appointments when needed. LPA reviewed centrally stored medication records. Medications were kept in the original containers. While visiting LPAs observed Home Health personnel and the visiting physician reviewing resident care.

Disaster Preparedness: The current emergency disaster forms were posted. The facility conducts quarterly disaster drills. The fire extinguishers were last inspected on 09/2024. Emergency exits and telephone numbers were posted. A set of keys is available for staff on all shifts to access full facility in an emergency.

Residents with Special Health Needs: The facility does accept dementia residents in care. The facility does not currently have residents with oxygen. The facility has 3 resident currently on hospice. The facility has 2 residents receiving Home Health services. Hospice and Home Health plans are kept up to date and on file. Hospice and Home Health train staff on residents care. The facility does not have delayed egress or locked doors. The facility has exiting door alarms.

LPA interviewed 2 staff working at the facility and 2 residents.

Exit interview conducted, deficiencies cited, copy of report and appeal rights printed for Administrator.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Garrett Haner-Tomasko
LICENSING EVALUATOR SIGNATURE:

DATE: 03/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2025
LIC809 (FAS) - (06/04)
Page: 9 of 10
Document Has Been Signed on 03/12/2025 04:54 PM - It Cannot Be Edited


Created By: Garrett Haner-Tomasko On 03/12/2025 at 04:16 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: CHERISH HOUSE RETREAT, INC.
FACILITY NUMBER: 405801741

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/12/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
87303(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on facility tour the licensee did not comply with the section cited above when LPA noted smoke detectors not working, exit door alarms not working, loose stair and ramp rails, ramp wood in disrepair, yard equipment and gasoline within access to residents, and room 6 water not meeting regulation (below 105*F) which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/19/2025
Plan of Correction
1
2
3
4
Administrator agreed to have maintenance and plumber out to fix water temperature, door alarms, rails and ramp. Smoke detector batteries were replace immediatly and functioning before LPAs left. Yard equipment and gasoline were moved to the shed and locked out of resident reach before LPAs left.
Type B
Section Cited
CCR
87307(a)(2)(C)
(a) Living accommodations and grounds shall be related to the facility's function. The facility shall be large enough to provide comfortable living accommodations and privacy for the residents, staff, and others who may reside in the facility. The following provisions shall apply:

(2) Resident bedrooms shall be provided which meet, at a minimum, the following requirements:

(C) No bedroom of a resident shall be used as a passageway to another room, bath or toilet.


This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA observation, the licensee did not comply with the section cited above when a resident walked through another residents room to use the "Jack and Jill" bathroom which poses a personal rights risk to persons in care.
POC Due Date: 03/19/2025
Plan of Correction
1
2
3
4
Administrator will email LPA a letter of understanding and documentation of staff training on Section 87307.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Kelly Burley
LICENSING EVALUATOR NAME:Garrett Haner-Tomasko
LICENSING EVALUATOR SIGNATURE:
DATE: 03/12/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/12/2025


LIC809 (FAS) - (06/04)
Page: 10 of 10