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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608838
Report Date: 09/10/2026
Date Signed: 09/10/2026 05:52:01 PM

Document Has Been Signed on 09/10/2026 05:52 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:VILLAGE AT NORTHRIDGE, THEFACILITY NUMBER:
197608838
ADMINISTRATOR/
DIRECTOR:		HELEN LEEFACILITY TYPE:
740
ADDRESS:9222 CORBIN AVETELEPHONE:
(818) 812-4610
CITY:NORTHRIDGESTATE: CAZIP CODE:
91324
CAPACITY: 194CENSUS: 178DATE:
09/10/2026
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Mary OkhataTIME VISIT/
INSPECTION COMPLETED:
06:00 PM
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Licensing Program Analyst (LPA) Mariana Agban and Licensing Program Manager (LPM) Mary Flores conducted an unannounced annual visit at the facility. The CARE inspection tool was not used due to technical issues. The domains were reviewed. LPA and LPM met with Mary Okahata Assisted Living Director and explained the reason for the visit.

Facility is licensed to serve as an Elderly Residential Facility (RCFE) for 194 non- ambulatory adults 60 and over, of which 3 may be bedridden in rooms 138,140,141. Facility has an approved hospice waiver for 30 residents. Facility consists of a lobby, library, two Bristo areas, a dining room, commercial kitchen, wellness office, medication room, fitness room, craft rooms, game room, activity rooms, and other common areas in the 2nd and 3rd floors. It consists of 3 floors and a basement, 4th floor houses residents in independent living, the first floor consists of common areas, some assisted living, basement consists of staff lounge and storage.

Department’s representative toured the facility with Maria Okahata the following domains were reviewed during this visit:

Operational Requirements: Facility maintains a plan of operation, infection control plan created and last reviewed on 04/02/26, fire clearance. Facility is operating within the limitations of their license. They have 4 residents under hospice. A current liability insurance was observed.

(CONTINUED ON LIC 809C)

Mary G Flores
Mariana Agban
DATE: 09/10/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/10/2026
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 S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: VILLAGE AT NORTHRIDGE, THE
FACILITY NUMBER: 197608838
VISIT DATE: 09/10/2026
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Physical Plant/Environmental Safety: During facility's tour all common areas were observed in good repair. A total of 17 random residents' rooms were observed, each room was furnished, with sufficient lighting, and bedding supplies. Water temperature was tested in each resident's bathroom and tested between 84.7 – 124.9 degrees F., which is not within the required 105-120 degrees F. Bathrooms were observed with grab bars and skid mats.

Medication is stored in medication rooms. Passageways, hallways, stairways are clear of debris and obstructions. Auditory signal/pendant buttons were tested for 4 residents and staff responded within less than 5 minutes. Facility has a fire sprinkler system throughout. Fire extinguishers were observed and last checked on 8/8/26. Elevators were observed working.

Resident Rights/Information: License, Let us Know (PUB 475), Ombudsman, personal rights posters were posted across activity room area.

Food Services: The commercial kitchen and observed good quality/commercial food supplies for at least 2 days of perishables and 7 days of non-perishables. Kitchen was observed clean and free of pest. Cleaning supplies were observed stored away from food supplies. Staff were observed practicing hygiene and infection prevention. One person was listed with a modified diet by the dining room.

Incidental Medical and Dental: Facility provides assistance with medical/dental arrangements and with medication assistance. Medications were observed stored in medication carts in each medication room. A review of medication for 10 residents was conducted. A log for PRN/Narcotics medication was observed. 5 out of 10 residents had medication listed that was not observed. Resident #2(R2) Atropine 1% eyedrops, Gentamicin 1%, Morphine Sulfate 100mg, Lorezapam 2mf, Hydrocodone-Apap 5-325mg per staff they have been discontinued. Resident #5(R5) Albuterol HFA 90mg, Iprat Albut .05, Dicoflinac gel. Resident #8(R8) Carisoprodol 250mg, Resident #9(R9) Albuterol HFA 90mg, Eszopidone 1mg, Promethazine 6.25mg, Resident #10(R10) Famotidine 10mg, Polyethylene Glycol 3350mg.

Disaster Preparedness: LPAs reviewed emergency disaster plan LIC 610E(3/19) last reviewed on 5/15/26. Evacuation chairs were observed in each staircase. Emergency drills are conducted monthly, last emergency drill was conducted on 09/05/26.

Infection Control: Facility maintains a copy of infection control and was last reviewed on 04/26. Housekeeping staff were observed maintaining sanitizing procedures and Chef was observed doing proper hand washing.

Deficiencies were noted on LIC 809D per Title 22 Regulations.

Exit interview was conducted and a copy of this report, LIC 809D, and appeal rights were provided.

NAME OF LICENSING PROGRAM MANAGER: Mary G Flores
NAME OF LICENSING PROGRAM ANALYST: Mariana Agban
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/10/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2026
LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 09/10/2026 05:52 PM - It Cannot Be Edited


Created By: Mariana Agban On 09/10/2026 at 05:10 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: VILLAGE AT NORTHRIDGE, THE
FACILITY NUMBER: 197608838

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/10/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/11/2026
Section Cited
CCR
87303(e)(2)

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(2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C) This requirement is not met as evidenced
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Executive Director agreed to provide proof of fixing the water temprature for the rooms menioned in the report. Proof will be emailed to the LPA by POC date.
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Based on observation, the licensee did not comply with the section cited above. Room#138 was 124.09 F, #270 was 99F, #273 was 84.7 and #208 was 121.6 F. This poses an immediate health, safety or personal rights risk to persons 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.
Mary G Flores
NAME OF LICENSING PROGRAM MANAGER:
Mariana Agban
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/10/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/10/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/10/2026 05:52 PM - It Cannot Be Edited


Created By: Mariana Agban On 09/10/2026 at 05:19 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: VILLAGE AT NORTHRIDGE, THE
FACILITY NUMBER: 197608838

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/10/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/17/2026
Section Cited
CCR
87464(f)(6)

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(f) Basic services shall at a minimum include:(6) Arrangements to meet health needs. This requirement is not met as evidenced.
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Executive Director agreed to audit medications list for all the residents mentioned. Proof of audit will be emailed to the LPA by the POC date.
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Based on observations, the licensee did not comply with the section cited above. Medications logs for R2, R4, R5, R8, R9, R10 listed medications that were not available for the residents. This poses a potential health, safety or personal rights risk to persons 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.
Mary G Flores
NAME OF LICENSING PROGRAM MANAGER:
Mariana Agban
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/10/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/10/2026


LIC809 (FAS) - (06/04)
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