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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850233
Report Date: 04/16/2025
Date Signed: 04/16/2025 01:21:34 PM

Document Has Been Signed on 04/16/2025 01:21 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:LIGHTFULLY-MOONBEAMFACILITY NUMBER:
565850233
ADMINISTRATOR/
DIRECTOR:		GINA GUERREROFACILITY TYPE:
772
ADDRESS:1247 LA PERESA DRIVETELEPHONE:
(858) 692-5374
CITY:THOUSAND OAKSSTATE: CAZIP CODE:
91362
CAPACITY: 6CENSUS: 4DATE:
04/16/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:50 AM
MET WITH:Corinne ElliottTIME VISIT/
INSPECTION COMPLETED:
01:30 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
Licensing Program Analyst (LPA) Angela Barutyan conducted an unannounced required annual inspection at the facility today. LPA arrived at 10:50AM and met with staff and Primary Therapist Nicole Beatty. Entrance interview conducted. LPA, along with Primary Therapist, toured the facility to ensure client health and safety and the facility is in compliance with Title 22 regulations. The following was observed:

Fire extinguishers were observed to be fully charged and last serviced 11/11/2024. Hardwired combination smoke and carbon monoxide detectors were tested at 11:22AM and were functional at the time of the visit. Auditory exit alarms in client bedrooms and common areas were tested and functional at the time of the visit.

KITCHEN: Appliances and fixtures appeared clean and functional. There was sufficient nonperishable food and perishable food. Knives and other sharps are stored in locked kitchen drawers and cabinets. Cleaning supplies were observed locked under the kitchen sink. Foods were labeled and checked for expiration dates. There were no visible immediate hazards observed.



TREATMENT/THERAPY, MEDICATION ROOM & OFFICE AREAS: There is a Group Room, Staff Office and Nurse's Office/Medication Room on the entry level. The medication room was observed to be locked and contains a locked medication cart. At 11:44AM, medications were reviewed for two (2) clients. Medications observed were properly labeled and medication records observed were documented per regulation. The First Aid Kit is stored in the Medication Room and was observed to be complete. The ground floor also contains an individual therapy room. The Offices are kept inaccessible to clients unless properly supervised.

Report Continued on LIC 809-C

NAME OF LICENSING PROGRAM MANAGER: Kristin Heffernan
NAME OF LICENSING PROGRAM ANALYST: Angela Barutyan
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/16/2025
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)
Page: 2 of 4
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: LIGHTFULLY-MOONBEAM
FACILITY NUMBER: 565850233
VISIT DATE: 04/16/2025
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
COMMON AREAS: The facility consists of 3 stories - the entry level and two lower levels. There are common areas found on each of the three (3) levels, including a Dining Room, living room, Art Room, and sitting area. All furniture appeared clean and in good condition.

LAUNDRY: Locked Laundry Room is located on the lower level by the Art Room. Laundry and cleaning supplies were observed to be inside a locked cabinet in the laundry room. Inside the laundry room is a locked IT closet, which also contained emergency supplies.

BEDROOMS: There are four (4) bedrooms, of which two (2) are private bedrooms and two (2) are designated for shared use. There are three (3) bedrooms located on the lower level and one (1) on the ground floor; all were observed to contain appropriate furniture, bedding and linens.

BATHROOMS: There are five (5) bathrooms. One (1) is in the nurse's office and is used mainly for staff. An additional one (1) bathroom on the entry level is for shared client, staff, and visitor use. One (1) private client bathroom and one (1) shared client bathroom are located on the lower level, and an additional one (1) client bathroom on the ground floor. All bathrooms were supplied with appropriate paper and hygiene products. Water temperature was measured in all client bathrooms and measured within the required range.

SURROUNDING GROUNDS: The backyard is fenced and includes various terraced landscaped areas, stairs and paved walkways/areas, including a patio and furniture appropriate for outdoor use as well as an outdoor fireplace. No immediate hazards were observed outdoors.

STAFF/CLIENT FILE REVIEW: LPA reviewed four (4) staff records during today's visit for documents including, but not limited to: training records, health screening and TB test. LPA reviewed four (4) client records during the visit for documents including but not limited to: Admission Agreement, physician's report, and needs and service appraisals. All staff and client records reviewed were in compliance.

INFECTION CONTROL/DISASTER PREPAREDNESS: During today’s visit, the LPA reviewed the facility's infection control policy and emergency disaster plan. Disaster drills are conducted quarterly as is required, with the last documented drill conducted on 04/01/2024. All documents reviewed were updated and in compliance.

Vice President of Nursing Corinne Elliott was present during the visit and was designated to sign this report.

No citations issued. Exit interview conducted. Today’s report was reviewed and provided.

NAME OF LICENSING PROGRAM MANAGER: Kristin Heffernan
NAME OF LICENSING PROGRAM ANALYST: Angela Barutyan
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/16/2025
LIC809 (FAS) - (06/04)
Page: 4 of 4