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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610739
Report Date: 10/06/2026
Date Signed: 10/06/2026 01:25:24 PM

Document Has Been Signed on 10/06/2026 01:25 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:PLATINUM CROWN INCFACILITY NUMBER:
197610739
ADMINISTRATOR/
DIRECTOR:		ALEKSANI, TAMARAFACILITY TYPE:
740
ADDRESS:20535 ENADIA WAYTELEPHONE:
(818) 740-1298
CITY:WINNETKASTATE: CAZIP CODE:
91306
CAPACITY: 6CENSUS: 4DATE:
10/06/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
07:45 AM
MET WITH:ALEKSANI, TAMARA- administratorTIME VISIT/
INSPECTION COMPLETED:
01:50 PM
NARRATIVE
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Licensing Program Manager (LPM) Mary Flores and Licensing Program Analyst (LPA) Leslie Ngo-Castaneda conducted an annual required visit and inspection of the facility. LPA met with staff, Behrouz Atri, and explained the reason for the visit. At 9:00 AM administrator, Tamara Aleksani, arrive and was explained the reason of the visit.

At 8:28 AM, with the assistance of the staff, LPM and LPA took a tour of the physical plant. Required postings were observed in the entry area. At 8:40 AM the smoke alarms were tested and are operational. There are carbon monoxide detectors that functions properly. The fire extinguisher is in the kitchen. The charge date is 5.4.2026. During the visit the facility is at 76 degrees Fahrenheit. The facility is fire cleared for six (06) non-ambulatory of which one (01) may be bedridden in bedroom 2, 3 and 4; bedroom #3 for bedridden; hospice waiver for five (5).

Kitchen: The kitchen appliances and fixtures were functional. The kitchen has a working electric stove, faucet, freezer, refrigerator, and microwave. LPA found enough at least two (2) days perishable and seven (7) days non-perishable food at the facility that is properly stored. Frozen foods are wrap, dated, and stored properly as well. Knives were stored in a locked drawer in the kitchen. LPM and LPA observe a knife in an accessible dishwasher, deficiency will be cited in LIC 809-D. R4 medication was observe to be accessible and unlock in the refrigerator. Office space is beside the kitchen.

Bedrooms: There were four (4) bedrooms designated for residents' and staff use. Three (3) of the that bedrooms are in use by residents were properly furnished with appropriate dresser, beddings, and linens with sufficient lighting. Bedroom #2, Bedroom #3, and bedroom #4 are shared, bedrooms has properly furnished. Bedroom #2 and bedroom #3 currently has only one (1) resident in each bedroom. Bedroom #1 is for staff use, their bedroom is unlocked with toxic chemicals in sight and was accessible. Deficiency will be cited in LIC 809-D. Bedroom #4 has a hornets nest on the patio and spiders were observed on the ceiling.

Continue to LIC 809-C
Mary G Flores
Leslie Ngo-Castaneda
DATE: 10/06/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/06/2026
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.

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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: PLATINUM CROWN INC
FACILITY NUMBER: 197610739
VISIT DATE: 10/06/2026
NARRATIVE
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Bathrooms: There are three (3) bathrooms designated for residents' and staff use. Bathrooms #1 were properly supplied and had functional fixtures. Hot water temperature was measured at 111.9 degrees Fahrenheit for bathroom #1 located beside bedroom #2. Bathroom #2 measured 118.5 degrees Fahrenheit located beside bedroom #2, located inside bedroom #2. Bathroom #3 is for staff use only located inside staff room. Cleaning supplies are being stored in a locked cabinets. Towels and washcloths are not shared. There was enough clean linen available in the cabinets in the hallway.

Common Areas: These included the living room and dining area for residents. The common areas were properly furnished. The auditory alarms on all bedroom exit doors were non-operational at the time of the visit. Deficiency will be cited in LIC 809-D. Residents dining table fits enough for six (6). Medications of the residents properly labeled were locked in the closet beside the entrance of the facility.

Surrounding Grounds: Entry and exits were free of obstruction. There was furniture appropriate for outdoor use. The outdoor area was free of hazards. The laundry area and detergents are located by the inside the closet that are kept secured. The facility does not have a swimming pool or body of water. There is no garage only car port.

Resident Files: LPA conducted a file review of resident records to ensure compliance of licensing forms. LPM and LPA observe R1 has S1 as the POA, deficiency will be cited in LIC 809-D.

Staff Files: LPA also conducted a file review of staff records to ensure forms and training are up to date and compliance with licensing forms.

Medications: Medication and Medication Records (MMR) were review for proper documentation. R4 medication was observe in bedroom #4 beside their night stand that was accessible and unlock. Deficiency will be cited in LIC 809-D.

Pursuant to Title 22 Division 6 of the CA Code of Regulations, deficiencies observed during the visit. Exit interview conducted and a copy of the report issued.
NAME OF LICENSING PROGRAM MANAGER: Mary G Flores
NAME OF LICENSING PROGRAM ANALYST: Leslie Ngo-Castaneda
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/06/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2026
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Document Has Been Signed on 10/06/2026 01:25 PM - It Cannot Be Edited


Created By: Leslie Ngo-Castaneda On 10/06/2026 at 11:52 AM
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: PLATINUM CROWN INC
FACILITY NUMBER: 197610739

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/06/2026

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
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Based on observation, the licensee did not comply with the section cited above in 1 out of 1, insect killer, aerosol, and knife were unlock and accessible to residents in care, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/07/2026
Plan of Correction
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Administrator lock chemicals in the closet. Knife was stored in a lock drawer.
Type A
Section Cited
CCR
87465(h)(1)(A)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (1) Medications shall be centrally stored under the following circumstances: (A) The preservation of medicines requires refrigeration, if the resident has no private refrigerator.

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 in 1 out of 1, R4 Lantus medication was accessible in the refrigerator, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/07/2026
Plan of Correction
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Administrator will purchase a lock to store refrigerated medications.
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:
Leslie Ngo-Castaneda
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/06/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/06/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/06/2026 01:25 PM - It Cannot Be Edited


Created By: Leslie Ngo-Castaneda On 10/06/2026 at 11:52 AM
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: PLATINUM CROWN INC
FACILITY NUMBER: 197610739

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/06/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(2)
Incidental Medical and Dental Care Services
(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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Based on LPM and LPA observation, the licensee did not comply with the section cited above in 1 out of 1 R4 medication was observe beside their night stand, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/07/2026
Plan of Correction
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Administrator immediately lock R4 medication.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:
Leslie Ngo-Castaneda
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/06/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/06/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/06/2026 01:25 PM - It Cannot Be Edited


Created By: Leslie Ngo-Castaneda On 10/06/2026 at 11:53 AM
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: PLATINUM CROWN INC
FACILITY NUMBER: 197610739

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/06/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPM and LPA observation, the licensee did not comply with the section cited above in 1 out of 1 bedroom #4 has a hornets nest outside the patio. Bedroom #4 has spiders on their ceiling, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/20/2026
Plan of Correction
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Administrator agreed to call an exterminator by POC date.
Type B
Section Cited
CCR
87127(D)(1)

(d) Except as provided in approved continuing care agreements, no licensee or employee of a facility shall:

(1) accept appointment as a guardian or conservator of the person and/or estate of any resident;
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPM and LPA record review, the licensee did not comply with the section cited above in 1 out of 1 R1 POA has S1 on it, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/20/2026
Plan of Correction
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Administrator agreed to assist R1 in obtaining a Public Guardian.
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:
Leslie Ngo-Castaneda
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/06/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/06/2026


LIC809 (FAS) - (06/04)
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