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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195850532
Report Date: 06/22/2026
Date Signed: 06/22/2026 04:35:39 PM

Document Has Been Signed on 06/22/2026 04:35 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:C&C SENIOR LIVING INCFACILITY NUMBER:
195850532
ADMINISTRATOR/
DIRECTOR:		HESHMATI, CLAUDIAFACILITY TYPE:
740
ADDRESS:6623 VESPER AVETELEPHONE:
(818) 913-2472
CITY:VAN NUYSSTATE: CAZIP CODE:
91405
CAPACITY: 6CENSUS: 4DATE:
06/22/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:17 AM
MET WITH:Claudia HeshmatiTIME VISIT/
INSPECTION COMPLETED:
04:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Trevor Byrne arrived at the facility unannounced to conduct the required annual visit at 10:17 AM. LPA met with facility staff who contacted the facility Administrator Claudia Heshmati. The Administrator arrived to the facility at 10:38 AM and the facility designee, Kevin Ohanian arrived later during the visit. Entrance interview conducted and the reason for the visit was explained.

Beginning at 10:40 AM the LPA, along with facility Administrator toured the physical plant areas inside and outside to ensure there are no health and safety hazards and that facility is in compliance with Title 22 Regulations. The following was observed:

COMMON AREAS: This included the living room, hallway, and dining area. LPA observed the living room to be clean and properly furnished at the time of the visit. The living room contained all required postings, a fireplace that was appropriately screened, a television, and activities for resident use. LPA observed the hallway to be clean and free from obstructions. The hallway contained closets which contained additional linens, emergency water, and activities. Additionally, LPA observed a locked closet which contained the facility’s washer/dryer and cleaning/laundry chemicals. The dining area was observed to be equipped with adequate seating for resident use. The facility’s fire and carbon monoxide alarms, along with the fire doors, were tested at 10:54 AM and were functional at the time of the visit. LPA observed cameras throughout the common areas of the facility.

CONTINUED ON LIC 809C.

NAME OF LICENSING PROGRAM MANAGER: Kasandra Lopez
NAME OF LICENSING PROGRAM ANALYST: Trevor Byrne
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 06/22/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/22/2026
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: C&C SENIOR LIVING INC
FACILITY NUMBER: 195850532
VISIT DATE: 06/22/2026
NARRATIVE
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KITCHEN: The LPA observed the kitchen area to be clean. Kitchen appliances appeared to be in operable condition. The facility had a sufficient supply of two (2) days perishable and seven (7) days non-perishable food. LPA observed a secured drawer which contained knives and other sharp objects. LPA observed a fire extinguisher mounted on the wall that was last serviced on 07/02/2024 which is outside of the required timeframe. The kitchen contained a locked under sink cabinet which contained cleaning supplies and an additional locked cabinet which contained resident medications and facility files.

BEDROOMS: There are four (4) bedrooms in the facility. LPA and the facility Administrator toured all four (4) bedrooms. All resident rooms were observed to be furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting. Bedroom #4 contained a direct exit to the outdoors of the facility. LPA observed bedroom #2 to contain cameras. The Administrator informed LPA that the cameras were installed at the request of the resident’s family. During file review LPA did not observe documentation in the resident’s file which showed that the family had the legal authority to make decisions on the residents behalf. Additionally, LPA did not observe any documentation from the residents family requesting cameras to be installed in the resident’s room.

BATHROOMS: There are two (2) bathrooms at the facility. One (1) a shared/common resident bathroom and one (1) is a private bathroom. Both resident bathrooms were observed to be clean and were equipped with nonskid surfaces. Grab bars were observed in all resident showers and near all resident toilets. All were properly secured. The water temperature was measured to be between 109.9 and 113.4 degrees Fahrenheit, which is within the range required by regulation.

OUTDOOR SPACE: The facility has one (1) emergency exit gate located in the front yard of the facility; LPA observed clear passageways for emergency exit use. The facility had adequate shaded seating outdoors for resident use. All ramps and railings were appropriately secured. LPA observed cameras located on the outdoors of the facility.

CONTINUED ON LIC 809C.

NAME OF LICENSING PROGRAM MANAGER: Kasandra Lopez
NAME OF LICENSING PROGRAM ANALYST: Trevor Byrne
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/22/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2026
LIC809 (FAS) - (06/04)
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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: C&C SENIOR LIVING INC
FACILITY NUMBER: 195850532
VISIT DATE: 06/22/2026
NARRATIVE
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RECORD REVIEW: Record review began at 11:29 AM. Staff and resident records were reviewed for documents including, but not limited to: health screening, TB test, staff training records, fingerprint clearance, resident physician's report, needs and service appraisal, consent forms, and personal rights. Six (6) staff files were reviewed. One staff file was observed to contain a blank health screening which was missing proof of a negative tuberculosis (TB) test, a physician’s signature, ability to perform duties, etc. Two (2) staff files were observed to be missing up to date first aid/CPR cards. One (1) staff training record was observed to be missing the number of hours completed per training subject. Four (4) resident files were reviewed. Two (2) resident files were observed to be missing proof of a negative TB test. One (1) resident medical assessment was observed to be missing all even numbered pages and was missing information including ambulatory status of the resident. Two (2) resident files were observed to be missing a signed copy of the personal rights of residents. Two (2) resident files were observed to be missing pre-admission appraisals of the residents.

MEDICATION REVIEW: Medication review began at 01:41 PM. Medications for two (2) of four (4) residents were observed. All medications were stored properly but no medications were appropriately documented on the resident’s centrally stored medication and destruction record sheets.

INFECTION CONTROL/EMERGENCY DISASTER PLANNING: During today’s visit, the LPA reviewed the facility's infection control practices and the facility's emergency disaster plan. The facility’s policies and procedures as they pertain to infection control are adequate. Emergency disaster drills are conducted quarterly; the facility’s last emergency disaster drill was conducted on 03/27/2026. The facility’s emergency disaster plan is up to date and is adequate. Both the infection control plan and the emergency disaster plan are reviewed/updated annually by the facility’s Administrator.

INTERVIEWS: LPA interviewed two (2) residents. The residents interviewed stated that the staff treat them well and are attentive to their needs. LPA interviewed one (1) staff member. The staff member interviewed was knowledgeable on their roles and responsibilities, the resident’s rights, the forms of abuse, and the appropriate reporting procedures for suspected abuse.

During today’s visit LPA obtained a copy of the facility’s LIC 500, resident roster, emergency disaster plan, and current liability insurance. 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 was issued and appeal rights provided.

NAME OF LICENSING PROGRAM MANAGER: Kasandra Lopez
NAME OF LICENSING PROGRAM ANALYST: Trevor Byrne
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/22/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2026
LIC809 (FAS) - (06/04)
Page: 4 of 10
Document Has Been Signed on 06/22/2026 04:35 PM - It Cannot Be Edited


Created By: Trevor Byrne On 06/22/2026 at 03:40 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: C&C SENIOR LIVING INC
FACILITY NUMBER: 195850532

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/22/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
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 facility's fire extinguisher was last purchased/serviced more than 12 months prior to inspection which poses a potential safety risk to persons in care.
POC Due Date: 07/06/2026
Plan of Correction
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Administrator agreed to submit proof of either a completed servicing of the fire extinguisher or a newly purchased fire extinguisher to CCLD no later than POC due date.
Type B
Section Cited
CCR
87468.2(a)(1)
87468.2 Additional Personal Rights of Residents in Privately Operated Facilities
(a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights:
(1) To have a reasonable level of personal privacy in accommodations, medical treatment, personal care and assistance, visits, communications, telephone conversations, use of the Internet, and meetings of resident and family groups.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above as the facility's admission agreement stated that no video surveillance is utilized at the facility and one resident room had cameras installed without documented consent or proof of the family's ability to make decisions on the resident's behalf which poses a potential personal rights risk to persons in care.
POC Due Date: 07/06/2026
Plan of Correction
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Administrator agreed to either remove all interior cameras from the facility or to create an addendum to their admission agreement for each resident and obtain signatures that acknowledge the use of video surveillance at the facility, obtain consent from the identified individual's family to install cameras in the resident's room, and obtain documentation which proves that the family has legal authority to make decisions on the resident's behalf. Administrator agreed to submit proof of either option being completed to CCLD no later than POC due date.
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:
Trevor Byrne
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/22/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/22/2026


LIC809 (FAS) - (06/04)
Page: 5 of 10
Document Has Been Signed on 06/22/2026 04:35 PM - It Cannot Be Edited


Created By: Trevor Byrne On 06/22/2026 at 03:40 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: C&C SENIOR LIVING INC
FACILITY NUMBER: 195850532

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/22/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(f)
Personnel Requirements - General
(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health.Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties.

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 as one employee's health screening was blank and was missing all required information which poses a potential health risk to persons in care.
POC Due Date: 07/06/2026
Plan of Correction
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Administrator agreed to submit a completed LIC 503 health screening for the identified employee including proof of a negative TB test to CCLD no later than POC due date.

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:
Trevor Byrne
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/22/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/22/2026


LIC809 (FAS) - (06/04)
Page: 6 of 10
Document Has Been Signed on 06/22/2026 04:35 PM - It Cannot Be Edited


Created By: Trevor Byrne On 06/22/2026 at 03:40 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: C&C SENIOR LIVING INC
FACILITY NUMBER: 195850532

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/22/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(c)(2)(D)
Personnel Records
(c) Licensees shall maintain in the personnel records verification of required staff training and orientation. (2) Documentation of staff training shall include: (D) Number of training hours per subject.

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 as one employee's training record was missing the number of hours completed for each training subject which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/06/2026
Plan of Correction
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Administrator agreed to complete a true and accurate training record for the identified employee which includes the number of training hours per subject and to send proof of the completed training log to CCLD no later than POC due date.
Type B
Section Cited
CCR
87468(b)(1)(A)
Personal Rights of Residents
(b) At the time the admission agreement is signed, a resident and the resident's representative shall be personally advised of and given a copy of: (1) The personal rights of residents specified in Sections 87468.1, Personal Rights of Residents in All Facilities and 87468.2, Additional Personal Rights of Residents in Privately Operated Facilities, as applicable to the facility. (A) The licensee shall have each resident and the resident's representative sign a copy of these rights, and the signed copy shall be included in the resident's record.

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 as two resident files were observed to be missing a signed copy of the personal rights of residents which poses a potential personal rights risk to persons in care.
POC Due Date: 07/06/2026
Plan of Correction
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Administrator agreed to send proof of a signed copy of the personal rights of residents for the identified residents to CCLD no later than POC due date.
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:
Trevor Byrne
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/22/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/22/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/22/2026 04:35 PM - It Cannot Be Edited


Created By: Trevor Byrne On 06/22/2026 at 03:40 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: C&C SENIOR LIVING INC
FACILITY NUMBER: 195850532

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/22/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87457(c)
Pre-Admission Appraisal
(c) Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of their individual service needs in comparison with the admission criteria specified in Section 87455, Acceptance and Retention Limitations.

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 as two new residents did not have a completed [re-admission appraisal before being accepted into the facility which poses a potential health or safety risk to persons in care.
POC Due Date: 07/06/2026
Plan of Correction
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Administrator agreed to complete an appraisal for the two residents and to send proof of the completed appraisal to CCLD no later than POC due date.
Type B
Section Cited
CCR
87458(c)
Medical Assessment
(c) The medical assessment shall include, but not be limited to:

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 as one resident medical assessment was observed to be missing even numbered pages including required information (TB test results, ambulatory status, etc.) and one resident medical assessment was observed to be missing proof of a negative TB test which poses a potential health risk to persons in care.
POC Due Date: 07/06/2026
Plan of Correction
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Administrator agreed to submit proof of a completed medical assessment for the identified individual and proof of a negative TB test for the identified individual to CCLD no later than POC due date.
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:
Trevor Byrne
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/22/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/22/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/22/2026 04:35 PM - It Cannot Be Edited


Created By: Trevor Byrne On 06/22/2026 at 04:01 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: C&C SENIOR LIVING INC
FACILITY NUMBER: 195850532

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/22/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(h)(6)
87465 Incidental Medical and Dental Care
(h) The following requirements shall apply to medications which are centrally stored:
(6) The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least one year and includes:
This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on record review, the licensee did not comply with the section cited above as no medications observed were appropriately documented on their CSMDRs and were missing all required information which poses a potential health risk to persons in care.
POC Due Date: 07/06/2026
Plan of Correction
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2
3
4
Administrator agreed to complete an accurate CSMDR for all residents of the facility. Administrator agreed to complete a statement of understanding confirming that they are aware of the importance of accurately logging medications in a timely manner and that they will adhere to medication documentation requirements for all future resident medications that come into the facility. Administrator agreed to submit the CSMDRs and the statement to CCLD no later than POC due date.
Section Cited
Deficient Practice Statement
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3
4
POC Due Date:
Plan of Correction
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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.
Kasandra Lopez
NAME OF LICENSING PROGRAM MANAGER:
Trevor Byrne
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/22/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/22/2026


LIC809 (FAS) - (06/04)
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