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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850242
Report Date: 08/18/2026
Date Signed: 08/19/2026 08:12:30 AM

Document Has Been Signed on 08/19/2026 08:12 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:NAVITA RESIDENCES EDGEMONTFACILITY NUMBER:
565850242
ADMINISTRATOR/
DIRECTOR:		SHILA PANDEYFACILITY TYPE:
740
ADDRESS:1690 EDGEMONT DRTELEPHONE:
(805) 413-2455
CITY:CAMARILLOSTATE: CAZIP CODE:
93010
CAPACITY: 6CENSUS: 5DATE:
08/18/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:45 AM
MET WITH:Shila PandeyTIME 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 9:45 A.M. The LPA was greeted by Caregiver, Maryanti FNU, and informed of the reason for the visit. Caregiver contacted the Administrator by phone, Shila Pandey. At 10:38 A.M. the Administrator arrived at the facility. LPA explained the reason for the visit. Entrance interview conducted.

Beginning at 11:00 A.M., the LPA along with the Administrator toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The following was observed:

Hardwired smoke detectors and Carbon Monoxide detectors were tested at 1:30 P.M. and were functional at the time of the visit. LPA observed one (1) fire extinguisher throughout the facility. The purchase date was missing; however, Administrator provided a receipt with 10/28/2024 as the purchase date. LPA explained to the Administrator that the fire extinguishers is required to be serviced annually to ensure it remains fully charged and in proper working condition. The Administrator acknowledged the requirements and agreed to service or replace the fire extinguisher annually and maintain proof of purchase or service attached to the equipment.

Continued on LIC 809-C

Desaree Perera
Valeria Conway
DATE: 08/18/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/18/2026
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
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: NAVITA RESIDENCES EDGEMONT
FACILITY NUMBER: 565850242
VISIT DATE: 08/18/2026
NARRATIVE
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Continued from LIC 809

BEDROOMS: The LPA observed the resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. There are 7 (seven) bedrooms in total; 1 (one) of which is designated as a staff room and 6 (six) are private resident rooms. LPA observed three (3) residents’ beds equipped with bedrails that extended the entire length of the bed. Currently no residents in care are receiving Hospice services. Administrator stated they were aware that full-length bed rails are only permitted for residents receiving hospice services. However, the Administrator stated that they were kept in place to prevent residents from falling out of bed. Full rails were removed during today’s visit. Technical Violation (TV) issued. Staff room was observed locked.

RESTROOMS: The LPA observed 3 (three) restrooms in the facility; 2 (two) are shared restrooms and one is a private restroom. Resident restrooms are sanitary and in operating condition with grab bars and slip-resistant surfaces. Water temperature was measured in all bathrooms and measured within the required range of 105 degrees Fahrenheit to 120 degrees Fahrenheit at the time of the visit.

COMMON SPACES: When LPA arrived at the facility, the LPA observed the fire door was prompt opened with a black rubber door stopper. In the common areas, walls and flooring were checked for cleanliness and good condition. At the time of the visit, living room and dining room furniture was observed to be in good condition. The LPA observed the required postings in the common area. A fireplace was observed to be adequately screened and inaccessible to residents. Auditorial signals were observed in each door around the facility. The facility maintained a temperature of 70 degrees Fahrenheit.

OUTDOOR SPACE: The backyard has a shaded seating area for residents to enjoy. The facility has one (1) side gate. The gate was observed to be self-closing and self-latching. The LPA did not observe any obstructions to emergency exit pathways. The garage is attached to the house and locked at all times. Garage contained the laundry area, extra food, emergency water and additional mobility devices. Cleaning supplies and chemicals are stored and inaccessible to residents.

Continued on LIC 809-C

NAME OF LICENSING PROGRAM MANAGER: Desaree Perera
NAME OF LICENSING PROGRAM ANALYST: Valeria Conway
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/18/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2026
LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 08/19/2026 08:12 AM - It Cannot Be Edited


Created By: Valeria Conway On 08/18/2026 at 03:02 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: NAVITA RESIDENCES EDGEMONT
FACILITY NUMBER: 565850242

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/18/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
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
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Based on observation, the licensee did not comply with the section cited above as the fire door was prompt open with a door stopper when LPA enter the facility to conduct the annual visit which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/19/2026
Plan of Correction
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Staff present closed the door during today's visit. Administrator and staff understands the importance of keeping this fire door closed at all times. Administrator stated that a handyman will come an install a magnet devise that connects to the smoke alarms to automatically shut the door in case of an emergency.
Type A
Section Cited
CCR
87465(c)(2)
Incidental Medical and Dental Care Services
(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (2) Once ordered by the physician the medication is given according to the physician's directions.

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 above as three (3) resident's medication had discrepancies on the documentation and on the on hand medication which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/19/2026
Plan of Correction
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Administrator agreed to hire a third-party vendor approved by the department to train staff on how to documentation, administratrion, re-filling medication, storing extra medication supply, and destruction of medication.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Desaree Perera
NAME OF LICENSING PROGRAM MANAGER:
Valeria Conway
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/18/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/18/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/19/2026 08:12 AM - It Cannot Be Edited


Created By: Valeria Conway On 08/18/2026 at 03:33 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: NAVITA RESIDENCES EDGEMONT
FACILITY NUMBER: 565850242

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/18/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87470(d)(6)
Infection Control Requirements 87470(d)(6) The Emergency Infection Control Plan shall be reviewed and updated as necessary or whenever new infection control measures are recommended by the federal, state, and local government public health authorities, or as determined by the Department, until the proclaimed or declared state of emergency is no longer in effect. Any updates to the plan shall be made available to staff, residents and if applicable, each resident’s representative, and submitted to the Department.

This requirement is not met as evidenced by:
Deficient Practice Statement
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LPA is issuing a citation after giving a technical violation on last year's annual. Administrator agreed to review and to update, if necessary, both plans and send a copy to LPA before POC due date. Administrator will also write a statement of understanding regarding this regulation.
POC Due Date: 09/01/2026
Plan of Correction
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Administrator agreed to write a statement of understanding regarding this regulation and update/review Infection control plan and submit a copy to LPA 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.
Desaree Perera
NAME OF LICENSING PROGRAM MANAGER:
Valeria Conway
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/18/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/18/2026


LIC809 (FAS) - (06/04)
Page: 5 of 6
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: NAVITA RESIDENCES EDGEMONT
FACILITY NUMBER: 565850242
VISIT DATE: 08/18/2026
NARRATIVE
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Continued fromLIC 809-C

KITCHEN: Kitchen appliances appeared to be in operable condition. The facility has a sufficient supply of perishable and non-perishable food, as well as emergency food. All knives and cleaning supplies were observed to be locked and properly stored at the time of the visit. At 11:45 A.M., hot water temperature measured 108.5 degrees Fahrenheit.

RECORD REVIEW: Record review began at 12:00 P.M., records were reviewed for but not limited to: health screening, TB test, staff training records, CPR certificate, fingerprint clearance, resident physician's report, needs and service appraisal, and personal rights. All records were in compliance with regulations. LPA reviewed five (5) staff files including the administrator’s file. LPA observed that the Administrator and Staff #1’s (S1’s) CPR certificate expired. Technical Assistance (TA) was issued.

MEDICATION REVIEW: Medications were observed locked in a cabinet across from the kitchen. Review began at 1:50 P.M. Medications for three (3) residents were observed. During the medication audit, LPA observed discrepancies for three (3) residents. The medication count on hand did not correspond with the documented medication start/open date and prescribed directions. For example, Resident #1 (R1) had a Metropolol bottle containing 25 pills remaining out of an original 90-count prescription. The medication directions indicated one pill per day; however, the documented open/start date was 09/2025.

LPA requested the following documentation, Personnel Record (LIC 500), Resident Roster (LIC 9020), and current liability insurance. Last emergency disaster drill was conducted on 06/30/2026. Additionally, LPA observed that the Infection Control Plan was not reviewed and/or updated annually, as required.

Pursuant to Title 22 CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D). One (1) civil penalty was issued, totaling $500.

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

NAME OF LICENSING PROGRAM MANAGER: Desaree Perera
NAME OF LICENSING PROGRAM ANALYST: Valeria Conway
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/18/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2026
LIC809 (FAS) - (06/04)
Page: 6 of 6