567610056-1-16-2025-29-AS-ABAN-DCYTBN-20250116133525

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 567610056
Report Date: 01/16/2025
Date Signed: 01/16/2025 01:35:45 PM

Document Has Been Signed on 01/16/2025 01:35 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:	APPLEGATE @ BERKSHIRE		FACILITY NUMBER:	567610056
ADMINISTRATOR/ DIRECTOR:	ALVAREZ, CYNTHIA		FACILITY TYPE:	740
ADDRESS:	2010 FULLBROKE DRIVE		TELEPHONE:	(805) 870-4400
CITY:	THOUSAND OAKS	STATE: CA	ZIP CODE:	91362
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS: 6	DATE:	01/16/2025
TYPE OF VISIT:	Case Management - Deficiencies	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	10:32 AM
MET WITH:	Irma Carmona		TIME VISIT/ INSPECTION COMPLETED:	01:45 PM

NARRATIVE

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Licensing Program Analyst (LPA) Angela Barutyan conducted a Case Management - Deficiencies visit in conjunction with a complaint visit (Complaint Control #29-AS-20250113113032). The purpose of the visit is to issue a citation for a deficiency observed during the initial complaint investigation.

During the visit on 01/16/2025, LPA reviewed three (3) personnel files and observed Staff #1’s (S1) file missing 20 hours annual training for 2024. S1 does not handle medications and interviews with staff, residents, and Licensee Irma Carmona confirmed that S1 does not administer or prepare medications. However, S1 was missing annual training for subjects including, but not limited to: dementia, aging, food preparation, and residents rights. Licensee stated they will create a training schedule for S1 to complete their 20 hours of annual training. The remaining two (2) personnel files observed were in order and had no missing documents or training.

The following deficiency was observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22. Administrator was informed that failure to correct deficiency may result in civil penalties.

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

Kristin Heffernan	TELEPHONE: (818) 596-4493
Angela Barutyan	TELEPHONE: 747-922-1234
	DATE: 01/16/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/16/2025

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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Document Has Been Signed on 01/16/2025 01:35 PM - It Cannot Be Edited

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: APPLEGATE @ BERKSHIRE	FACILITY NUMBER: 567610056
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/16/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

87411 Personnel Requirements - General (c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69 This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4
	POC Due Date: 01/30/2025
	Plan of Correction
1 2 3 4	Licensee agreed to create a training plan for S1's 20 hours of annual training and send proof of the plan to CCL by 01/30/2025.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Kristin Heffernan	TELEPHONE: (818) 596-4493
Angela Barutyan	TELEPHONE: 747-922-1234
	DATE: 01/16/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/16/2025

LIC809 (FAS) - (06/04)

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