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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850512
Report Date: 06/18/2025
Date Signed: 06/18/2025 03:36:55 PM

Document Has Been Signed on 06/18/2025 03:36 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:ELEMENTAL HEALTHFACILITY NUMBER:
565850512
ADMINISTRATOR/
DIRECTOR:		DOBBS, SHANNONFACILITY TYPE:
772
ADDRESS:145 ERTEN ST.TELEPHONE:
(805) 857-6449
CITY:THOUSAND OAKSSTATE: CAZIP CODE:
91360
CAPACITY: 6CENSUS: 4DATE:
06/18/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:15 AM
MET WITH:Dr. Shannon Dobss - Clinical Director TIME VISIT/
INSPECTION COMPLETED:
03:45 PM
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Licensing Program Analyst (LPA) Erica Mosley arrived at the facility unannounced to conduct a required annual visit at 10:15 a.m. LPA Mosley was greeted by Staff / Operations Manager, Anna Pinkerman who called the Administrator to inform them of the visit. The Administrator / Licensee Representative / Clinical Director, Dr. Shannon Dobbs arrived shortly after and the reason for the visit was explained. Entrance interview conducted. LPA and staff toured the physical plant areas inside and outside to ensure there are no immediate health and safety hazards and facility is in compliance with Title 22 Regulations.

BEDROOMS: There are four (4) total bedrooms in the facility; two (2) bedrooms are designated as private, single occupancy, client rooms and two (2) are designated for shared, double occupancy, client rooms. All client rooms were observed to be furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting.

BATHROOMS: There are three (3) total Bathrooms, one (1) is designated as a private client restroom, one (1) is a shared client restroom and one (1) is designated for staff/guests. All restrooms were supplied with appropriate paper and hygiene products. The hot water temperature was measured in all client bathrooms between 2:20 p.m. -2:25 p.m. and measured between 108.7 – 115.0 degrees Fahrenheit all within the required range.

KITCHEN: The LPA inspected the kitchen/food service area at 2:23 p.m. Knives and other sharps were observed to be locked in the chef pantry. Kitchen appliances were in operable condition.

Report Continued on LIC 809C...

NAME OF LICENSING PROGRAM MANAGER: Kasandra Lopez
NAME OF LICENSING PROGRAM ANALYST: Erica Mosley
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 06/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/18/2025
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 3
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: ELEMENTAL HEALTH
FACILITY NUMBER: 565850512
VISIT DATE: 06/18/2025
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(PAGE 2) Report Continued from LIC 809C...
The facility has a sufficient supply of two (2) day perishable and seven (7) day non-perishable food. Refrigerator and food pantry were checked for proper labels and expiration dates. The kitchen faucet was measured for hot water temperature, and it measured 111.6 degrees Fahrenheit at 2:26 p.m. Cleaning supplies and other chemicals are kept locked in an under-sink cabinet inaccessible to clients in care. Adjacent to the kitchen is the facility's laundry room. Laundry room contains a locked chemical cabinet.

SURROUNDING GROUNDS: The Front Yard includes a driveway, walkways and landscaped areas. The backyard includes both paved and landscaped areas, a patio, furniture appropriate for outdoor use, shaded area, as well as an in-ground pool, which is kept fully enclosed with a locked fence. There is an outdoor building, which includes a group room and locked storage area. All passageways were observed to be clear and free from hazard.

COMMON AREAS: TREATMENT/THERAPY, MEDICATION ROOM & OFFICE AREAS: These include the living room, dining room, and meditation/sitting room, Group Room, therapy room and medication room/office in the locked garage. In the common areas, walls, flooring and furniture was observed and all were in good condition at the time of the visit. There is a fireplace in the living room which was observed to be disabled. The facility maintained a comfortable temperature. At 2:19 p.m., hardwire combination of smoke / carbon monoxide detector were tested and operational at the time of the visit. The fire extinguisher was observed and fully charged on 03/11/2025. The emergency exiting plans/sketch are posted in every room. The emergency telephone numbers are posted in common hallway. The LPA observed required postings throughout the common space. Activities were observed in the common areas. LPA observed an adequate amount of emergency food and water.

GARAGE: Lower level attached garage was observed to be locked. Garage is utilized as a staff office and medication room. Medications are locked inside the locked garage. Facility vehicles were observed parked in front of the facility. Facility vehicle appeared to be in operable condition.

Due to time constraints the LPA will return to complete the annual at a later date. During today's inspection, the facility is in compliance with Title 22 regulations. No citations issued. Exit interview conducted. Copy of report provided.

NAME OF LICENSING PROGRAM MANAGER: Kasandra Lopez
NAME OF LICENSING PROGRAM ANALYST: Erica Mosley
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2025
LIC809 (FAS) - (06/04)
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