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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610706
Report Date: 06/07/2026
Date Signed: 06/07/2026 06:39:55 PM

Document Has Been Signed on 06/07/2026 06:39 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 S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:AZALEA HOUSEFACILITY NUMBER:
197610706
ADMINISTRATOR/
DIRECTOR:		HEWITT, AMBERFACILITY TYPE:
740
ADDRESS:1952 MAIDEN LANETELEPHONE:
(626) 239-9051
CITY:ALTADENASTATE: CAZIP CODE:
91001
CAPACITY: 6CENSUS: 6DATE:
06/07/2026
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:15 AM
MET WITH:Caregivers, Luis Mendez, Imen Moussa and Administrator, Amber HewittTIME VISIT/
INSPECTION COMPLETED:
07:00 PM
NARRATIVE
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In conjunction with complaint investigation, Licensing Program Analyst (LPA) Antonia Alvizar-Ettima conducted a case management visit to address the deficiencies unrelated to the complaint.

Prior to this visit during Complaint Investigation on 12/12/25, LPA Alvizar-Ettima reviewed resident R1’s physician report and noted that it was not signed by resident and resident’s physician. The Administrator was advised that the licensee shall obtain a medical assessment, signed by a licensed medical professional acting within the scope of their practice and made within the last year. The complete document shall be part of the resident's record. At the time of this visit Administrator indicated that it was the only physician report that they had in R1’s record file.

During this licensing visit, LPA Alvizar-Ettima discovered that staff#1, (S1) Luis Ernesto Mendez DOB: 08/07/1989 have been present without a Criminal Background Clearance and not Association to this facility. S1 has been working at facility since 11/10/25 providing care to the residents. LPA requested S1’s Identification Card and S1 stated that they did not have it. Later, S1 text Administrator a picture of their Republica De El Salvador identification card. LPA Alvizar-Ettima was informed that S1 has been transferred from La Casita Residential. LPA reviewed Licensing database and Criminal Background System and S1’s names did not appeared on Azalea House and Las Casita Residential facility records. S1 immediately left the facility. Administrator was advised that S1 cannot return until they have approved Criminal Background Clearance and Association to this facility.

During today’s physical plan tour LPA, Alvizar-Ettima observed that the first bedroom where resident #2-#3 (R2-R3) reside was being cosmetically repainted. No health and safety concerns were identified. A technical violation was provided regarding Department notification requirements for future physical plant modifications. The Administrator acknowledged understanding.

Under Title 22, Division 6. Chapter 8, following Citations and civil penalty and technical violation were issued and recorded on LIC809D. Exit interview was conducted, appeal rights provided and a copy of report was issued.

NAME OF LICENSING PROGRAM MANAGER: Naira Margaryan
NAME OF LICENSING PROGRAM ANALYST: Antonia Alvizar-Ettima
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 06/07/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/07/2026
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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Document Has Been Signed on 06/07/2026 06:39 PM - It Cannot Be Edited


Created By: Antonia Alvizar-Ettima On 06/07/2026 at 05:39 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., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: AZALEA HOUSE
FACILITY NUMBER: 197610706

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/07/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/08/2026
Section Cited
CCR
87355(e)(3)c)

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87355 Criminal Record Clearance. (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing, or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 87355(c).
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 Administrator agreed that Staff #1 (S1) will not return until they have approved Criminal Background Clearance and Association to this facility. S1 immidiatelty left the facility and POA was cleared during today's visit.
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This requirement is not met as evidenced by staff #1 working in the facility since 11/10/25 and had no criminal record/ association to the facility. This poses an immediate hazard to the health and safety to residents in care.
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Type B
06/22/2026
Section Cited
CCR87458(a)

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87458 Medical Assessment (a) Prior to a person's acceptance as a resident, the licensee shall obtain documentation of a medical assessment, signed by a licensed medical professional acting within the scope of their practice and made within the last year, to be kept in the resident's record.
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Administrator agreed to obtain Medical Assessment signed by their physician and person prior to acceptance as a resident. R1 no longer resides in the faciltiy.
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This requirement was not meet as evidenced by. R1’s physician report was not signed by the doctor. This poses potential risk to health, safety and personal rights to residents in care.
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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.
Naira Margaryan
NAME OF LICENSING PROGRAM MANAGER:
Antonia Alvizar-Ettima
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/07/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/07/2026


LIC809 (FAS) - (06/04)
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