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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405850130
Report Date: 03/17/2025
Date Signed: 03/17/2025 11:21:34 AM

Document Has Been Signed on 03/17/2025 11:21 AM - 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:GINA SCHWICHTENBERG ARF IIFACILITY NUMBER:
405850130
ADMINISTRATOR/
DIRECTOR:		SCHWICHTENBERG, GINAFACILITY TYPE:
735
ADDRESS:285 HEADWATERS RDTELEPHONE:
(805) 286-4008
CITY:TEMPLETONSTATE: CAZIP CODE:
93465
CAPACITY: 4CENSUS: 4DATE:
03/17/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
07:30 AM
MET WITH:Staff - Trey CorreyTIME VISIT/
INSPECTION COMPLETED:
11:30 AM
NARRATIVE
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At 7:30am on 03/17/2025, Licensing Program Analysts (LPA) Haner-Tomasko and Jeffries, arrived unannounced at the facility to conduct the annual facility inspection. LPAs met with Primary Staff Trey Correy (S1), announced who they are, and the reason for the visit.
S1 and LPA conducted a full tour of the facility. The facility is a 3-bedroom 2.5-bathroom house, with a living room, kitchen, and dining area. There are two client bedrooms that are dual occupancy and one primary bedroom for the live-in staff. The clients share a full and half bathroom. The other full bathroom is attached to the primary bedroom. LPA noted that the bathrooms are clean and functioning. Hand soap and paper towels available in each one. LPA tested and noted the facility water temperature to be 116.5*(f), within regulation range of 105*-120* (f). LPA observed a first aid kit in the laundry room. The laundry room is locked and that is where the chemicals and medication are kept. There is a patio with shade pergola and umbrella in the back yard for client to use. LPA noted a fire extinguisher fully charged and inspected January 2025. LPA noted smoke alarms located in each room throughout the facility and carbon monoxide detector in the hallway. LPA observed at least two days of perishable foods and more than seven days of non-perishable foods on hand at this facility. LPA noted that the facility telephone was operational.
LPA noted that the facility was new, clean and in good repair. LPA noted that all doors and exits were free of obstructions. LPA reviewed centrally stored medications, staff files and client files. LPA noted one client admission agreement to be incomplete. Infection control and emergency/disaster plans reviewed.
S1 and LPA conducted a review of the annual control tools modules.

Exit interview conducted, deficiencies cited, copy of report and appeal rights provided.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Garrett Haner-Tomasko
LICENSING EVALUATOR SIGNATURE: DATE: 03/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/17/2025
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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Document Has Been Signed on 03/17/2025 11:21 AM - It Cannot Be Edited


Created By: Garrett Haner-Tomasko On 03/17/2025 at 10:59 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: GINA SCHWICHTENBERG ARF II
FACILITY NUMBER: 405850130

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/17/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80068(a)
Admission Agreements
(a) The licensee shall complete an individual written admission agreement with each client and the client's authorized representative, if any.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review the licensee did not comply with the section cited above when LPA noted a client's (C1) incomplete admission agreeement (the cost of rent line, admnistrator and resposible person's signature to be missing, client's signature present) which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/31/2025
Plan of Correction
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Administrator will email LPA the completed admission agreement by 03/31/2025. Including signature of client's responsible person.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
SUPERVISOR'S NAME:Kelly Burley
LICENSING EVALUATOR NAME:Garrett Haner-Tomasko
LICENSING EVALUATOR SIGNATURE:
DATE: 03/17/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/17/2025


LIC809 (FAS) - (06/04)
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