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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195850612
Report Date: 06/15/2026
Date Signed: 06/15/2026 05:53:40 PM

Document Has Been Signed on 06/15/2026 05:53 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:LAUREL CANYON RESIDENTIAL CAREFACILITY NUMBER:
195850612
ADMINISTRATOR/
DIRECTOR:		HARUTYUNYAN, KRISTINEFACILITY TYPE:
740
ADDRESS:8054 LAUREL CANYON BLVDTELEPHONE:
(747) 474-9514
CITY:NORTH HOLLYWOODSTATE: CAZIP CODE:
91605
CAPACITY: 6CENSUS: 5DATE:
06/15/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:16 AM
MET WITH:Kristine HarutyunyanTIME VISIT/
INSPECTION COMPLETED:
06:00 PM
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Licensing Program Analyst (LPA) Trevor Byrne arrived at the facility unannounced to conduct the required annual visit at 10:16 AM. LPA met with the facility Administrator Kristine Harutunyan and later the Assistant Administrator Mariam Harutunyan. Entrance interview conducted and the reason for the visit was explained.

Beginning at 10:18 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:

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 fire extinguisher mounted on the wall to be purchased on 05/31/2026. The kitchen contained a locked under sink cabinet which contained chemicals and a secured drawer which contained knives and other sharp objects. LPA observed a locked cabinet that contained resident medications. LPA observed an unsecured daily pill organizer which contained medications. LPA notified the Administrator who immediately secured the medications.

BEDROOMS: There are four (4) bedrooms in the facility; three (3) are dual occupancy resident rooms and one (1) is a staff room. 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. One (1) resident bed was observed to contain full bed rails. Bedrooms #3&4 contained direct exits to the outdoors of the facility. LPA observed the staff bedroom to be unlocked and LPA observed unsecured supplements. LPA notified the Administrator who immediately secured the staff bedroom.

Continued on LIC 809C.

NAME OF LICENSING PROGRAM MANAGER: Kasandra Lopez
NAME OF LICENSING PROGRAM ANALYST: Trevor Byrne
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 06/15/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/15/2026
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 15
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: LAUREL CANYON RESIDENTIAL CARE
FACILITY NUMBER: 195850612
VISIT DATE: 06/15/2026
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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 a television and adequate seating. The hallway was observed to contain two closets which contained care supplies and dry food storage. The dining area was observed to be equipped with adequate seating for resident use. All furniture throughout the facility was observed to be clean and in good repair. The facility’s combination fire and carbon monoxide alarms were tested at 11:21 AM and functioned properly at the time of the visit. All exits in the facility were observed to contain functioning auditory alarms.

BATHROOMS: There are two (2) bathrooms at the facility. One (1) designated as a private resident bathroom, one (1) is designated as a staff bathroom. The resident bathroom was observed to be clean and was equipped with nonskid surfaces. Grab bars were observed in the resident shower and near the resident toilet, all were properly secured. The water temperature was measured to be between 112.8 and 118.9 degrees Fahrenheit, which is in compliance with regulation. LPA observed the resident bathroom to have secured under sink storage which contained cleaning chemicals. LPA observed an unsecured bottle of bleach in an unsecured cabinet in the resident bathroom. LPA notified the Administrator who immediately secured the item. LPA observed the staff bathroom to contain the facility’s washer and dryer.

OUTDOOR SPACE: The facility has one (1) emergency exit gate located at the front of the facility; LPA observed clear passageways for emergency exit use. The facility had adequate shaded seating outdoors for resident use. LPA observed cameras located throughout the outdoor areas of the facility.

RECORD REVIEW: Record review began at 11:24 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. Three (3) staff files were reviewed. LPA observed all three (3) staff files to be missing a completed Criminal Record Statement (LIC 508). LPA observed two (2) staff files to be missing a valid first aid/CPR card. LPA informed the Assistant Administrator and Administrator that staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross. The Administrator agreed to contact the trainer who provided the training to obtain a valid First Aid/CPR card. LPA observed one (1) staff file to contain twenty (20) hours of initial training but the file was observed to be missing the additional twenty (20) hours of required training to be completed within the first four (4) weeks of employment. Continued on LIC 809C.

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

DATE: 06/15/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2026
LIC809 (FAS) - (06/04)
Page: 3 of 15
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: LAUREL CANYON RESIDENTIAL CARE
FACILITY NUMBER: 195850612
VISIT DATE: 06/15/2026
NARRATIVE
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RECORD REVIEW CONT.: Five (5) resident files were reviewed. LPA observed one (1) resident to be missing proof of a negative TB test. LPA informed the Assistant Administrator who agreed to obtain proof of a negative TB test for the resident. LPA observed one (1) resident admission agreement to be missing the amount charged for basic services. LPA informed the Assistant Administrator that admission agreements shall specify the rate for all basic services which the facility is required to provide. The assistant Administrator expressed understanding and agreed to revise the admission agreement with the resident and the resident’s responsible party. LPA observed one (1) resident’s bed to contain full bed rails. LPA observed that the resident was not enrolled in hospice care. LPA informed the Assistant Administrator that bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails. The Assistant Administrator expressed understanding and agreed to remove the bed rails.

MEDICATION REVIEW: Medication review began at approximately 01:00 PM. Medications for three (3) of five (5) residents were observed. All medications were stored properly. LPA observed two (2) medications that were not logged on their respective Centrally Stored Medication and Destruction Record Sheets (CSMDRs). LPA informed the Assistant Administrator who logged the medications at the time of the visit.

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. LPA observed the infection control plan to not be reviewed/updates annually. LPA informed the Assistant Administrator that the licensee shall review the use of infection control procedures in the facility at least annually. The Assistant Administrator agreed to conduct a review of the facility’s infection control plan. Emergency disaster drills are to be conducted quarterly. The facility’ was unable to provide LPA proof of the last completed disaster drill. The facility’s emergency disaster plan was not reviewed/updated annually and contained outdated information.

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 role and responsibilities, the resident’s rights, the different forms of abuse, and the appropriate reporting procedures for suspected abuse.

Continued on LIC 809C.

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

DATE: 06/15/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2026
LIC809 (FAS) - (06/04)
Page: 4 of 15
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: LAUREL CANYON RESIDENTIAL CARE
FACILITY NUMBER: 195850612
VISIT DATE: 06/15/2026
NARRATIVE
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During today’s visit LPA obtained a copy of the facility’s emergency disaster plan, and current liability insurance. The facility was unable to provide LPA with an updated LIC 500 or resident roster. 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: 06/15/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2026
LIC809 (FAS) - (06/04)
Page: 5 of 15
Document Has Been Signed on 06/15/2026 05:53 PM - It Cannot Be Edited


Created By: Trevor Byrne On 06/15/2026 at 04:17 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: LAUREL CANYON RESIDENTIAL CARE
FACILITY NUMBER: 195850612

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/15/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space and Access
(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above as a bottle of bleach was left in an unsecured drawer in the resident bathroom which posed an immediate health and safety risk to persons in care.
POC Due Date: 06/15/2026
Plan of Correction
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2
3
4
Administrator secured the bleach at the time of the visit. POC cleared.
Type A
Section Cited
CCR
87465(h)(2)
(h) The following requirements shall apply to medications which are centrally stored:
(2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation, the licensee did not comply with the section cited above as a daily pill organizer which contained medications was left outside of locked storage which posed an immediate health and safety risk to persons in care.
POC Due Date: 06/15/2026
Plan of Correction
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2
3
4
Administrator secured the organizer at the time of the visit. POC cleared.
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: 06/15/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/15/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/15/2026 05:53 PM - It Cannot Be Edited


Created By: Trevor Byrne On 06/15/2026 at 04:17 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: LAUREL CANYON RESIDENTIAL CARE
FACILITY NUMBER: 195850612

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/15/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87470(c)(1)(D)
Infection Control Requirements
(c) An Infection Control Plan shall be developed by the licensee and shall be included in the Plan of Operation required by Section 87208. (1) The Infection Control Plan shall include all of the following: (D) The licensee shall review the use of infection control procedures in the facility at least annually, if local government public health determines an epidemic outbreak has occurred, or if the review is requested by the local licensing agency.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above as the facility's infection control plan was not updated or reviewed annually which poses a potential health risk to persons in care.
POC Due Date: 06/29/2026
Plan of Correction
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2
3
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Administrator agreed to review the facility's infection control plan and to send a copy of the reviewed/updated infection control plan to CCLD no later than POC due date.
Section Cited
Deficient Practice Statement
1
2
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: 06/15/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/15/2026


LIC809 (FAS) - (06/04)
Page: 7 of 15
Document Has Been Signed on 06/15/2026 05:53 PM - It Cannot Be Edited


Created By: Trevor Byrne On 06/15/2026 at 04:17 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: LAUREL CANYON RESIDENTIAL CARE
FACILITY NUMBER: 195850612

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/15/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.625(b)(1)
Other Provisions
(1) The department shall adopt regulations to require staff members of residential care facilities for the elderly who assist residents with personal activities of daily living to receive appropriate training. This training shall consist of 40 hours of training. A staff member shall complete 20 hours, including six hours specific to dementia care, as required by subdivision (a) of Section 1569.626 and four hours specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696, before working independently with residents. The remaining 20 hours shall include six hours specific to dementia care and shall be completed within the first four weeks of employment. The training coursework may utilize various methods of instruction, including, but not limited to, lectures, instructional videos, and interactive online courses. The additional 16 hours shall be hands-on training.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above as one employee file was observed to be missing the additional 20 hours of training to be completed within the first 4 weeks of employment which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/29/2026
Plan of Correction
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3
4
Administrator agreed to conduct 20 hours of additional training with the identified employee and to send proof of the completed training 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: 06/15/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/15/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/15/2026 05:53 PM - It Cannot Be Edited


Created By: Trevor Byrne On 06/15/2026 at 04:17 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: LAUREL CANYON RESIDENTIAL CARE
FACILITY NUMBER: 195850612

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/15/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(c)(1)
Personnel Requirements - General
(1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above as two staff files did not contain valid CPR/first aid cards which poses a potential health and safety risk to persons in care.
POC Due Date: 06/29/2026
Plan of Correction
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2
3
4
Administrator agreed to provide proof of valid CPR/first aid training completed by a trainer qualified through an appropriate agency for the identified employees to CCLD no later than POC due date.
Type B
Section Cited
CCR
87465(b)
Incidental Medical and Dental Care Services
(b) If the resident's physician has stated in writing that the resident is able to determine and communicate his/her need for a prescription or nonprescription PRN medication, facility staff shall be permitted to assist the resident with self-administration of his/her PRN medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above as five resident files were observed to be missing PRN authorization forms and three residents were observed to have PRN medications prescribed to them which poses a potential health risk to persons in care.
POC Due Date: 06/29/2026
Plan of Correction
1
2
3
4
Administrator agreed to obtain completed PRN authorizations for all residents and to submit proof of the completed authorizations 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: 06/15/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/15/2026


LIC809 (FAS) - (06/04)
Page: 9 of 15
Document Has Been Signed on 06/15/2026 05:53 PM - It Cannot Be Edited


Created By: Trevor Byrne On 06/15/2026 at 04:17 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: LAUREL CANYON RESIDENTIAL CARE
FACILITY NUMBER: 195850612

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/15/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87458(c)(1)(A)
Medical Assessment
(c) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the licensed medical professional's diagnosis or diagnoses and results of an examination for all of the following: (A) Communicable tuberculosis.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above as one resident was missing proof of a negative TB test which poses a potential health risk to persons in care.
POC Due Date: 06/29/2026
Plan of Correction
1
2
3
4
Administrator agreed to obtain proof of a negative TB test for the identified individual and to submit proof of the negative TB test to CCLD no later than POC due date.
Type B
Section Cited
CCR
87508(b)
Register of Residents
(b) Registers of residents shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. Registers may be removed if necessary for copying. Removal of registers shall be subject to the following requirements:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above as the facility did not have an updated resident roster available for inspection which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/29/2026
Plan of Correction
1
2
3
4
Administrator agreed to complete a resident roster and to send CCLD the completed roster 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: 06/15/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/15/2026


LIC809 (FAS) - (06/04)
Page: 10 of 15
Document Has Been Signed on 06/15/2026 05:53 PM - It Cannot Be Edited


Created By: Trevor Byrne On 06/15/2026 at 04:17 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: LAUREL CANYON RESIDENTIAL CARE
FACILITY NUMBER: 195850612

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/15/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(a)
Other Provisions
(a)In addition to any other requirement of this chapter, a residential care facility for the elderly shall have an emergency and disaster plan that shall include, but not be limited to, all of the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above as the facility's emergency disaster plan contained inaccurate and out of date information which poses a potential safety risk to persons in care.
POC Due Date: 06/29/2026
Plan of Correction
1
2
3
4
Administrator agreed to update the facility's emergency disaster plan and to send a copy of the updated plan to CCLD no later than POC due date.
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above as the facility did not have proof of the last completed emergency disaster drill which poses a potential safety risk to persons in care.
POC Due Date: 06/29/2026
Plan of Correction
1
2
3
4
Administrator agreed to complete an emergency disaster drill and to send proof of the completed drill 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: 06/15/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/15/2026


LIC809 (FAS) - (06/04)
Page: 11 of 15
Document Has Been Signed on 06/15/2026 05:53 PM - It Cannot Be Edited


Created By: Trevor Byrne On 06/15/2026 at 04:17 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: LAUREL CANYON RESIDENTIAL CARE
FACILITY NUMBER: 195850612

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/15/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(d)
Other Provisions
(d) A facility shall review the plan annually and make updates as necessary, including changes in floor plans and the population served. The licensee or administrator shall sign and date documentation to indicate that the plan has been reviewed and updated as necessary.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above as the facility's emergency disaster plan was not updated/reviewed annually which poses a potential safety risk to persons in care.
POC Due Date: 06/29/2026
Plan of Correction
1
2
3
4
Administrator agreed to review/update the facility's emergency disaster plan and to send proof of the updated plan to CCLD no later than POC due date.
Type B
Section Cited
CCR
87608(a)(5)(B)
Postural Supports
(B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and record review, the licensee did not comply with the section cited above as one resident's bed contained full bed rails and the resident was not a hospice client which poses a potential personal rights risk to persons in care.
POC Due Date: 06/29/2026
Plan of Correction
1
2
3
4
Administrator agreed to remove the full bed rails from the resident's bed and to send proof of the removal 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: 06/15/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/15/2026


LIC809 (FAS) - (06/04)
Page: 12 of 15