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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850244
Report Date: 06/03/2025
Date Signed: 06/03/2025 04:12:42 PM

Document Has Been Signed on 06/03/2025 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:PALS SKILLS CENTERFACILITY NUMBER:
565850244
ADMINISTRATOR/
DIRECTOR:		POURAN MOUSAZADEHFACILITY TYPE:
775
ADDRESS:1310 E MAIN STREETTELEPHONE:
(562) 489-3859
CITY:SANTA PAULASTATE: CAZIP CODE:
93060
CAPACITY: 30CENSUS: 7DATE:
06/03/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:30 AM
MET WITH:Jesus Landeros TIME VISIT/
INSPECTION COMPLETED:
04:20 PM
NARRATIVE
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Licensing Program Analyst (LPA) Esther Cortez arrived at the facility unannounced to conduct a required annual visit at 11:30 a.m. The LPA met with Program Director Jesus Landeros and explained the reason for the visit. Upon arrival, there were three (3) consumers and three (3) staff in the building, and four (4) consumers were on an outing with three (3) staff. The program currently operates from 8:00 a.m. to 2:00 p.m.

Common Activity Space: The facility is a single-story structure with a large conference room, two (2) calming/meeting rooms, one (1) relaxing/therapy room, one (1) computer area, one (1) meal area, one (1) staff room, two (2) small kitchens, and two (2) bathrooms. The LPA did not observe any obstructions or hazards. Furniture and equipment was observed to be in good condition. At 11:50 a.m. the LPA observed one (1) smoke alarm in a calming room non-operable, otherwise all other smoke alarms and carbon monoxide detectors were tested and functioned properly during time of visit. The LPA observed fire extinguisher which was fully charged and last serviced 06/11/2024. Program Director stated the fire extinguisher would get serviced before 06/11/25.

Activities: Activities are both designed for individual and as a group. Four (4) of the seven (7) enrolled Consumers were out at an outing.

Food Service: The kitchen areas were clean and in good condition. Consumers bring their lunch and snacks. The facility has emergency food supplies and snacks available for consumers.

Restrooms: Restrooms were clean and sanitary and stocked with soap and paper towels. Water temperature in the restroom was measured at 118.6 degrees Fahrenheit. Report will continue on LIC809-C

NAME OF LICENSING PROGRAM MANAGER: Kasandra Lopez
NAME OF LICENSING PROGRAM ANALYST: Esther Cortez
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 06/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/03/2025
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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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: PALS SKILLS CENTER
FACILITY NUMBER: 565850244
VISIT DATE: 06/03/2025
NARRATIVE
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Record Review: At 12:20 p.m. a review of facility files was initiated. The LPA observed documentation of Infection Control, Disaster prevention, and Insurance liability. The LPA obtained Client Roster, Staff Roster. The LPA reviewed three (3) out of seven (7) Client Files. One (1) client file had a needs and service plan more than a year old. The LPA reviewed four (4) of eleven(11) staff files. One (1) of four (4) staff (S1) was not finger printed cleared. LPA reviewed Guardian and LIS Facility Personnel Summary for S1. On Guardian it appeared as "fingerprints not taken" and separation date of "09/13/2024". S1 has been working for a year at the facility.

Medications: The LPA conducted a medication audit for two (2) client and the following was observed. Medications are centrally stored and locked in a locked cabinet in the reception area; Medications are not being documented on the Centrally Stored medications and Destruction record therefore, the LPA was unable to determine if medications were administered correctly.

Interview: During today's visit, the LPA interviewed two (2) clients. No immediate concerns voiced at this time.

Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D). Exit interview conducted and copy of the report and appeal rights provided to Administrator.

NAME OF LICENSING PROGRAM MANAGER: Kasandra Lopez
NAME OF LICENSING PROGRAM ANALYST: Esther Cortez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

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


Created By: Esther Cortez On 06/03/2025 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: PALS SKILLS CENTER
FACILITY NUMBER: 565850244

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/03/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
82020
Fire Clearance
All day programs shall secure through the licensing agency and maintain a fire clearance approved by the city or county fire department, the 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 in one (1) smoke alarm that was observed non-operable during the visit which poses an immediate health, and safety risk to persons in care.
POC Due Date: 06/03/2025
Plan of Correction
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POC Cleared: during today's visit a new smoke detector was placed.
Type A
Section Cited
HSC
1522(c)(1)
General Provisions
(c)(1) Subsequent to initial licensure, a person specified in subdivision (b) who is not exempted from fingerprinting shall obtain either a criminal record clearance or an exemption from disqualification pursuant to subdivision (g) of this section or Section 1522.7 from the State Department of Social Services prior to employment, residence, or initial presence in the facility.

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 in one (1) staff that did not have a fingerprint clearance and not associated to the facility which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/04/2025
Plan of Correction
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License will submit a self-certification letter that they will ensure S1 obtains fingerprint clearance and associated to the facility before working any further at the facility and that they undertand regulation 1522(c)(1) .
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Kasandra Lopez
NAME OF LICENSING PROGRAM MANAGER:
Esther Cortez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/03/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/03/2025


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


Created By: Esther Cortez On 06/03/2025 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: PALS SKILLS CENTER
FACILITY NUMBER: 565850244

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/03/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
82075(I)(7)
82075(l)(7) Health Related Services. The licensee shall ensure the maintenance, for each client, of a record of centrally stored prescription medications which is retained for at least one year and includes specified information.

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 in two out of two clients that did not have a centrally stored medication record which poses an immediate health and safety risk to persons in care.
POC Due Date: 06/13/2025
Plan of Correction
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Program Director agreed to have all staff that issues medication recieve training on medication record keeping and create a centrally stored medication records for both clients. Will submit proof of training by 06/13/2025.
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.
Kasandra Lopez
NAME OF LICENSING PROGRAM MANAGER:
Esther Cortez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/03/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/03/2025


LIC809 (FAS) - (06/04)
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