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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565801456
Report Date: 03/11/2025
Date Signed: 03/12/2025 09:34:33 AM

Document Has Been Signed on 03/12/2025 09:34 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:CEDAR HOUSEFACILITY NUMBER:
565801456
ADMINISTRATOR/
DIRECTOR:		LOUISA MAE ESPENAFACILITY TYPE:
735
ADDRESS:161 MARKER AVENUETELEPHONE:
(805) 484-0271
CITY:CAMARILLOSTATE: CAZIP CODE:
93010
CAPACITY: 6CENSUS: 6DATE:
03/11/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:30 AM
MET WITH:Louisa CervantesTIME VISIT/
INSPECTION COMPLETED:
04:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Valeria Conway arrived at the facility unannounced to conduct a required annual visit at 10:30 A.M. The LPA initially met with staff member Maria Elena Villarico. The Administrator, Louisa Nolan was contacted via telephone and arrived at 11:05 A.M. LPA explained the reason for today's visit. Entrance interview conducted.

The facility is vendored through Tri-Counties Regional Center as a level 3 home. The Facility does handle cash resources for some of the clients.



Beginning at 11:20 A.M., the LPA, along with Administrator toured the physical plant areas inside and outside to ensure there are no health and safety hazards and the facility is in compliance with Title 22 Regulations. The following was observed:

Individual smoke alarms and separate carbon monoxide detector were tested between 11:35 A.M. - 12:02 P.M. and all functioned properly. The fire extinguisher was observed to be fully charged and last serviced on 03/05/2024. During today’s visit a new fire extinguisher was purchased. No fire clearance concerns were observed during today's visit.



OUTDOOR SPACE: The backyard patio contains a shaded area and is equipped with furniture for clients' use. An outdoor shed was observed to be locked. All passageways and exits were observed to be clear and free of hazards. Facility has two total gates; both were observed to be self-closing and self-latching gate with clear passageways for emergency exit use.

Continued on LIC 809-C
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Valeria Conway
LICENSING EVALUATOR SIGNATURE: DATE: 03/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/11/2025
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 6
Document Has Been Signed on 03/12/2025 09:34 AM - It Cannot Be Edited


Created By: Valeria Conway On 03/11/2025 at 03:12 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: CEDAR HOUSE
FACILITY NUMBER: 565801456

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/11/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited aboves as all client bathrooms and kitchen water temperature were measured above 129 degrees which poses an immediate health and safety risk to persons in care.
POC Due Date: 03/11/2025
Plan of Correction
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Administrator lowered thermostat and agrees to keep weekly water temperature log.
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:Desaree Perera
LICENSING EVALUATOR NAME:Valeria Conway
LICENSING EVALUATOR SIGNATURE:
DATE: 03/11/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/11/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/12/2025 09:34 AM - It Cannot Be Edited


Created By: Valeria Conway On 03/11/2025 at 03:12 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: CEDAR HOUSE
FACILITY NUMBER: 565801456

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/11/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80025(b)
Bonding
(b) All licensees, other than governmental entities, who are entrusted to care for and control clients' cash resources shall file or have on file with the licensing agency, a bond issued by a surety company to the State of California as principal.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record revied], the licensee did not comply with the section cited above by not ensuring proof of surety bond was kept in the facility which poses a potential personal rights risk to clients in care.
POC Due Date: 03/25/2025
Plan of Correction
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The administrator shall submit proof the facility has a surety bond to cover the amount of P&I money being held in the facility by POC due date.
Type B
Section Cited
CCR
80066(a)(10)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (10) A health screening as specified in Section 80065(g).

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 by having S1's file missing their health screening form which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/25/2025
Plan of Correction
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Licensee will have S1 obtain a health screening and submit evidence to CCL on or before POC due date.
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:Desaree Perera
LICENSING EVALUATOR NAME:Valeria Conway
LICENSING EVALUATOR SIGNATURE:
DATE: 03/11/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/11/2025


LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 03/12/2025 09:34 AM - It Cannot Be Edited


Created By: Valeria Conway On 03/11/2025 at 03:12 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: CEDAR HOUSE
FACILITY NUMBER: 565801456

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/11/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80065(f)
Personnel Requirements
(f) All personnel shall be given on-the-job training or shall have related experience which provides knowledge of and skill in the following areas, as appropriate to the job assigned and as evidenced by safe and effective job performance.

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 by having 3 out of 4 staff without on-the-job training which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/25/2025
Plan of Correction
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Administrator agrees to have all 3 staff trained before POC due date.
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:Desaree Perera
LICENSING EVALUATOR NAME:Valeria Conway
LICENSING EVALUATOR SIGNATURE:
DATE: 03/11/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/11/2025


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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: CEDAR HOUSE
FACILITY NUMBER: 565801456
VISIT DATE: 03/11/2025
NARRATIVE
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Continued from LIC 809

COMMON SPACES: Living room, dining room, and activity room furniture was observed to be in good condition. The LPA observed the required postings upon entry and throughout the common areas. The facility maintained a comfortable temperature. Facility provides sufficient space to accommodate both indoor and outdoor activities. LPA observed a working phone available for residents use whenever needed. Cash resources are kept locked in a file cabinet located in the activity room.

BEDROOMS: The LPA observed three shared client bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. The facility also contains a locked staff room.

RESTROOMS: 1 (one) restroom is designated for shared client use and 2 (two) are private restrooms, attached to client bedrooms. Client restrooms were observed to be clean and sanitary and in operating condition. Between 11:41 A.M. and 11:51 A.M hot water was checked in the shared client restrooms and measured between 129.0-137.4 degrees Fahrenheit.

KITCHEN: Knives are stored in a locked drawer. Kitchen appliances appeared to be in operable condition. The facility has a sufficient supply of perishable and non-perishable food. LPA conducted a review of expiration dates on product labels. At 11:54 A.M. hot water measured 138.9 degrees Fahrenheit.

GARAGE: LPA observed the facility garage which contained extra food, locked cleaning supplies, locked laundry supplies, emergency food and water as well as the laundry area.

CLIENT FILES/CASH RESOURCES: At 12:35 P.M. LPA reviewed six (6) client files for, but not limited to: physician's report, proof of TB test, Admission Agreement, annual service plans/IPPs, medical assessments, and cash resources. All six (6) client files observed were in compliance with regulation.

STAFF FILES: At 1:50 P.M. LPA reviewed four (4) staff files for, but not limited to: fingerprint background clearance, health screening, TB test, and training records. LPA observed Staff #1 (S1), Staff #2 (S2), and Staff #3 (S3) missing training hours, also S1 did not have a completed Health screening report (LIC 503).

Continued on LIC 809-C

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Valeria Conway
LICENSING EVALUATOR SIGNATURE:

DATE: 03/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2025
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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: CEDAR HOUSE
FACILITY NUMBER: 565801456
VISIT DATE: 03/11/2025
NARRATIVE
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Continued from LIC 809-C

MEDICATION REVIEW: Beginning at 2:36 P.M, LPA reviewed medications for 4 (four) clients. All medications reviewed were documented and stored in compliance with regulation.

INFECTION CONTROL/EMERGENCY DISASTER PLANNING: During today’s visit, the LPA reviewed the facility's infection control practices and the facility's emergency disaster plan. The facility’s policies and procedures as it pertains to infection control are adequate. Emergency disaster drills are conducted monthly, with the last drill documented on 02/15/2025. Emergency disaster plan was observed to be complete and updated annually as required.

At the beginning of the annual inspection, the LPA requested the Personnel Record (LIC 500), Register of facility Clients/Residents LIC 9020, Liability Insurance and Surety Bond. As of 3:30 P.M., the administrator was unable to provide proof of liability insurance or surety bond.

INTERVIEWS: Throughout the duration of today's visit, all clients were out of the facility. LPA interview one (1) staff member.

The following deficiencies were observed and cited from the California Code of Regulations, Title 22 and/or California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties.

Exit interview conducted. A copy of the report and appeal rights were provided.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Valeria Conway
LICENSING EVALUATOR SIGNATURE:

DATE: 03/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2025
LIC809 (FAS) - (06/04)
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