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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405850543
Report Date: 08/19/2025
Date Signed: 08/19/2025 03:59:43 PM

Document Has Been Signed on 08/19/2025 03:59 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:YOUNG ADULT FAMILY HOMEFACILITY NUMBER:
405850543
ADMINISTRATOR/
DIRECTOR:		D0LLY SCHWEDFACILITY TYPE:
735
ADDRESS:1949 L STREETTELEPHONE:
(805) 467-5004
CITY:SAN MIGUELSTATE: CAZIP CODE:
93451
CAPACITY: 4CENSUS: 4DATE:
08/19/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:00 PM
MET WITH:Licensee - Diane YoungTIME VISIT/
INSPECTION COMPLETED:
04:00 PM
NARRATIVE
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At 2:00pm on 08/19/2025, Licensing Program Analyst (LPA) Haner-Tomasko arrived unannounced to the facility to conduct a case management visit along with Tri-Counties Regional Center (TCRC). LPA met with Licensee Diane Young and announced the reason for the visit.

On 8/13/2025 Tri-County Regional Center brought to Community Care Licensing’s (CCL) attention, that an incident occurred at this facility on 8/11/2025. The Licensee submitted an incident report to TCRC on 08/13/2025. According to the incident report and staff interviews on 8/11/2025 around 7:50 pm Client #1 (C1) ran from their bedroom to the garage pulling the back of Staff #1’s (S1) hair from behind while screaming at him "Fuck you (S1’s name)". C1 then ran back inside and crouched down by the front door. When S1 enter the home from the garage, C1 attacked S1 throwing punches at their head and scratching them while screaming "I'm going to kill you". As S1 was being attacked, S1 did his best to restrain C1 by wrapping their arms around C1’s chest, while C1’s arms were raied in the air, but C1 was still throwing punches at S1 causing C1 to break free several times resulting in property damage. C1 and S1 ended up on the ground, C1 stopped physically attempting to hurt S1 and C1 went to their room. S1 held C1 around the chest for about 10 seconds. Client #2 (C2) and Client #3 (C3) were in their room, heard commotion, and locked their door. Staff #2 (S2) assisted Client #4 (C4) to live-in staff bedroom and locked the door. Licensee communicated with C2 and C3 via text message until it got calm and quiet. Licensee stated no one called 911 or the crisis unit as they were afraid it would make it worse. C1’s TCRC Service Coordinator is working with the facility and C1 to find a facility better suited for C1’s needs and as of today’s visit C1 is tentatively scheduled to move before the end of the month.

(Continued on LIC809-D)

NAME OF LICENSING PROGRAM MANAGER: Kelly Burley
NAME OF LICENSING PROGRAM ANALYST: Garrett Haner-Tomasko
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 08/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/19/2025
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 4
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: YOUNG ADULT FAMILY HOME
FACILITY NUMBER: 405850543
VISIT DATE: 08/19/2025
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LPA conducted a case management visit on 4/3/2025 regarding two other incidents with C1 and the Licensee states another incident occurred on 7/14/2025 where C1 ran at them, the Licensee ran around to the opposite side of the kitchen bar, the Licensee and C1 spoke across the bar and C1 calmed down. Licensee admits they did not submit an incident report for the incident on 7/14/2025 to TCRC or CCL. After prompting from the LPA, the licensee submitted an incident report for the incident on 8/11/2025 to Licensing on 8/18/2025.

During LPA annual visit to the facility on 5/28/2025 LPA asked S1 about C1 and their current situation. S1 stated things had been going well at that time and C1 had not had any outbursts.

LPA observed a cot in the living room behind the couch that C4 is currently using and has been using for about three weeks because C1 expressed they did not like rooming with C4. C4 did not make this decision to room on the cot on their own. This adjustment is being made until C1 moves out.

Due to the Licensee not reporting incidents to CCL per Title 22 Regulations and being cited for this previously during case management visits conducted on 8/2/2024 and 9/12/2024 a deficiency was cited.

Exit interview, deficiencies cited on LIC809-D, a civil penalty in the amount of $250 for a repeat violation within 12 months is being assessed on the LIC 421FC, report signed, report and appeal rights provided to Licensee.

NAME OF LICENSING PROGRAM MANAGER: Kelly Burley
NAME OF LICENSING PROGRAM ANALYST: Garrett Haner-Tomasko
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/19/2025 03:59 PM - It Cannot Be Edited


Created By: Garrett Haner-Tomasko On 08/19/2025 at 03:40 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: YOUNG ADULT FAMILY HOME
FACILITY NUMBER: 405850543

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/19/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/02/2025
Section Cited
CCR
80061(b)(1)(E)

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Reporting Requirements (b)Upon the occurrence…a report shall be made to the licensing agency within the agency's next working day…In addition, a written report…shall be submitted to the licensing agency within seven days…(1)Events reported shall include the following:
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On or before 9/2/2025, Licensee will submit to LPA by email a statement of understanding of this regualtion and how they will ensure rports are submitted to CCL moving forward.
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following:(E)Any unusual incident…which threatens the physical or emotional health or safety of any client. This requirement was not met as evidenced by: Based on interview and record review, the licensee did not report to licensing as required which poses a potential health, safety,
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and personal rights risk to persons in care.
Type B
09/02/2025
Section Cited
CCR85087(a)(3)

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Buildings and Grounds (a)In addition to Section 80087, bedrooms must meet, at a minimum, the following requirements:
(3) No room commonly used for other purposes shall be used as a bedroom for any person. This requirement was not met as evidenced by:
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On or before 9/2/2025, Licensee will submit to LPA by email a statement of understanding of this regualtion, how it's a resident rights violation, and potential safety and frie hazard. Licensee will ensure C4 returns to their room and feels safe there.
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Based on observation, when LPA observed a cot in the living room where C4 is sleeping which poses a potential health, safety, and personal rights risk to persons in care.
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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: 08/19/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/19/2025


LIC809 (FAS) - (06/04)
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