197610410-10-5-2026-31-AS-NSHN-DYKVSA-20261005164112

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610410
Report Date: 10/05/2026
Date Signed: 10/05/2026 04:41:25 PM

Document Has Been Signed on 10/05/2026 04:41 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:	VAGTHOL'S RESIDENTIAL CARE CENTER #2		FACILITY NUMBER:	197610410
ADMINISTRATOR/ DIRECTOR:	ROMERO, ELIZABETH		FACILITY TYPE:	740
ADDRESS:	751 S. MARIPOSA STREET		TELEPHONE:	(323) 788-9924
CITY:	BURBANK	STATE: CA	ZIP CODE:	91506
CAPACITY: 6		CENSUS: 5	DATE:	10/05/2026
TYPE OF VISIT:	Case Management - Other	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	03:30 PM
MET WITH:	Elizabeth Romero-Administrator		TIME VISIT/ INSPECTION COMPLETED:	04:30 PM

NARRATIVE

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Licensing Program Analyst (LPA) Nadia Shahbazian conducted an unannounced case management visit. LPA was greeted by Administrator Elizabeth Romero and explained the reason for the visit.

LPA conducted a physical plant tour, to ensure the health and safety of the residents were protected and the physical plant was in compliance with Title 22 Regulations, no health or safety issues were observed.

On 07/30/26, 08/06/26 and 08/25/26 incident reports were received in Woodland Hills South Regional Office regarding Client 1 (C1). In addition a death report was received on 09/03/26 regarding C1, who passed away on 09/03/26 in Sherman Oaks Hospital.

Based on incident report on 07/30/26, C1 was taken to hospital for hematuria and released on 07/31/26. On 08/06/26 at approximately 10:10pm during routine rounds, staff observed C1 exhibiting wheezing and shallow respirations. Due to low oxygen saturation at 10:27pm 911 paramedics transported C1 to Providence St. Joseph Hospital and was admitted to ICU. On 08/14/26 client was transferred to Sherman Oaks Rehabilitation while experiencing hypotension, oxygen desaturation and receiving oxygen via nasal cannula. C1’s responsible parties were notified during each incident. Due to client’s change of condition and medical evaluation, C1 was transferred to Sherman Oaks Hospital on 08/25/26 and admitted to ICU. On 08/30/26 C1 was intubated and placed on mechanical ventilation due to persistent low oxygen saturation and low blood pressure. On 09/03/26, following discussion with the medical team, C1’s family elected to withdraw the ventilator support and transition C1 to comfort-focused care to prevent further suffering. C1 passed away on 09/03/26, in Sherman Oaks Hospital, under care of attending physician. A copy of C1’s death report was later received with cause of death due to natural causes.

During today’s visit LPA interviewed the staff who informed LPA of C1’s condition. Staff stated C1 was taken to hospital several times and to Sherman Oaks SNF and transported to hospital again. LPA reviewed C1’s physician record, physician orders for life-sustaining treatment (POLST) and hospital records.

No deficiencies sited. Exit interview conducted and a copy of the report was provided.

Mary G Flores
Nadia Shahbazian
	DATE: 10/05/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2026

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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