425800790-3-13-2025-29-AS-GHTO-DEQV7C-20250313161056

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 425800790
Report Date: 03/13/2025
Date Signed: 03/13/2025 04:12:33 PM

Document Has Been Signed on 03/13/2025 04:12 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:	SUPERIOR RESIDENTIAL CARE FACILITY FOR THE ELDERLY		FACILITY NUMBER:	425800790
ADMINISTRATOR/ DIRECTOR:	ERIC SO HU		FACILITY TYPE:	740
ADDRESS:	1034 DONALD WAY		TELEPHONE:	(805) 937-0939
CITY:	SANTA MARIA	STATE: CA	ZIP CODE:	93455
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS: 4	DATE:	03/13/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	10:30 AM
MET WITH:	Backup Administrator - Laarni So Hu		TIME VISIT/ INSPECTION COMPLETED:	04:20 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 10:30am on 03/13/2025, Licensing Program Analysts (LPA)s Garrett Haner-Tomasko and Melisa Rankin arrived unannounced to the facility to conduct the annual inspection. LPA met with Administrator Laarni So Hu and announced the purpose of the visit. Licensee and LPAs reviewed facility clearance roster and confirmed all staff working were on the facility roster and all cleared. Licensee and LPAs conducted a cursory tour of the facility. This facility is a seven-bedroom, 4 bathroom home with kitchen, two living rooms and dining room. There is a large center courtyard with a pergola that provided shade for residents. Five of the bedrooms are single occupancy resident rooms, the other bedrooms are for live-in staff. LPA observed that all bath rooms were stocked with liquid soap and paper towels. LPA observed each resident room and all rooms are in compliance with regulation standards with appropriate bedding, lighting, and storage. LPA noted that each room had its own exit, and all exits were free and clear of obstructions and hazards. LPA noted that smoke detectors and carbon monoxide detectors were functioning at the time of visit. Toilet, hand washing and bathing facilities are operational and secured grab bars are present. The showers have non-skid mats/flooring. The pathways are clear of any obstructions. Facility is well lit inside and outside for safety. The facility has a fenced backyard for client use with plenty of shade. The facility has telephone and internet service for resident use. LPA observed and cited for fire extinguisher due to it being purchased in 2023 and not tested since. LPA observed at least 2 days of perishable and at least seven days of non-perishable foods. LPA tested facility water temperature and noted that it was within regulation parameters of 105*-120P(f). (Continued LIC809-C)

Kelly Burley	TELEPHONE: (805) 562-0413
Garrett Haner-Tomasko	TELEPHONE: (805) 450-0283
	DATE: 03/13/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/13/2025

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 03/13/2025 04:12 PM - It Cannot Be Edited

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: SUPERIOR RESIDENTIAL CARE FACILITY FOR THE ELDERLY	FACILITY NUMBER: 425800790
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/13/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

HSC

1569.618(c)(3)

Other Provisions

(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on records review, the licensee did not comply with the section cited above, 5 of 5 staff do not hold current CPR and First Aid training which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 03/14/2025
	Plan of Correction
1 2 3 4	In the next 24 hours administrator will have enough staff trained in CPR and First Aid to ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. Receipt of training and certificates will be emailed to LPA.

Type A

Section Cited

CCR

87465(h)(2)

Incidental Medical and Dental Care Services

(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. 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 liquid narcotic was found unlocked in the kitchen refrigerator and the garage door was unlocked where the medication storage is located, the medication storage was also unlocked which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 03/14/2025
	Plan of Correction
1 2 3 4	Administrator will obtain locking box for refrigerated medications and send a photo of the box to LPA by 03/14/2025. Administrator will email an understanding of Section 87465 of TItle 22 regulations and documentation of training staff on this section by 03/13/2025.

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	TELEPHONE: (805) 562-0413
Garrett Haner-Tomasko	TELEPHONE: (805) 450-0283
	DATE: 03/13/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/13/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 03/13/2025 04:12 PM - It Cannot Be Edited

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: SUPERIOR RESIDENTIAL CARE FACILITY FOR THE ELDERLY	FACILITY NUMBER: 425800790
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/13/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

CCR

87202(a)

Fire Clearance

(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal: 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 the fire extinguisher in the kitchen was noted to be purchased in 7/2023 and has not been replaced or inspected since which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/20/2025
	Plan of Correction
1 2 3 4	Administrator will replace fire extiguisher before or by 3/20/2025 and email photo of receipt and new extinguisher to LPA.

Type B

Section Cited

CCR

87309(a)

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. 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 unlocked sharps, matches, and chemicals were noted in the kitchen accessible to residents which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/20/2025
	Plan of Correction
1 2 3 4	Administrator immediately removed and locked up items during LPA facility tour.

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	TELEPHONE: (805) 562-0413
Garrett Haner-Tomasko	TELEPHONE: (805) 450-0283
	DATE: 03/13/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/13/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 03/13/2025 04:12 PM - It Cannot Be Edited

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: SUPERIOR RESIDENTIAL CARE FACILITY FOR THE ELDERLY	FACILITY NUMBER: 425800790
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/13/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

CCR

87555(b)(8)

General Food Service Requirements

(b) The following food service requirements shall apply: (8) All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained. 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 rotting vegetables were noted in the refrigerator which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/20/2025
	Plan of Correction
1 2 3 4	Administrator removed vegetables before LPAs left visit.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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	TELEPHONE: (805) 562-0413
Garrett Haner-Tomasko	TELEPHONE: (805) 450-0283
	DATE: 03/13/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/13/2025

LIC809 (FAS) - (06/04)

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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: SUPERIOR RESIDENTIAL CARE FACILITY FOR THE ELDERLY	FACILITY NUMBER: 425800790
	VISIT DATE: 03/13/2025

NARRATIVE

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During LPAs tour of the kitchen area medication was found on the kitchen counter, narcotics were discovered unlocked in the refrigerator, unlocked cabinets containing scissors were observed. While touring the garage, LPAs found that the door was unlocked, and the garage contained chemicals and knives which were accessible to residents in care. LPAs observed staff entering and exciting garage door various times and when asked they stated they locked the door at night, but during the day staff are monitoring. All items noted above were cited.

While reviewing facility records, staff have annual training completed for all subjects/topics and hours for 2024. It was noted that CPR and 1^st Aid training certificates were not valid and needed updating, this is a safety concern for residents in care, facility was cited.

LPAs conducted interviews with all 4 residents in care. Residents all noted that they feel safe and supported in the facility, they have no concerns or complaints. LPA observed 3 out of the 4 residents with visitors, all visitors were allowed to enter and communicated efficiently and with ease with administrator.

Exit interview done, annual report, citations, and appeal rights were printed and provided to administrator. Further time is needed, annual will be completed at a later

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Garrett Haner-Tomasko	TELEPHONE: (805) 450-0283
LICENSING EVALUATOR SIGNATURE:	DATE: 03/13/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/13/2025

LIC809 (FAS) - (06/04)

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