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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565801597
Report Date: 10/07/2026
Date Signed: 10/07/2026 12:58:32 PM

Document Has Been Signed on 10/07/2026 12:58 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:A LOVING HEART SENIOR CAREFACILITY NUMBER:
565801597
ADMINISTRATOR/
DIRECTOR:		DIORENA ROCK/ MICHEAL V.FACILITY TYPE:
740
ADDRESS:28 WALES STREETTELEPHONE:
(805) 230-3818
CITY:THOUSAND OAKSSTATE: CAZIP CODE:
91360
CAPACITY: 6CENSUS: 4DATE:
10/07/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:45 AM
MET WITH:Micheal Vicente - Manager
Diorena "Rocky" Rock - Licensee		TIME VISIT/
INSPECTION COMPLETED:
01:05 PM
NARRATIVE
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Licensing Program Analyst (LPA) Erica Mosley arrived at the facility unannounced to conduct a required annual visit and entered the facility at approx. 9:45 a.m. Upon arrival, LPA Mosley was greeted by staff and the Administrator / Licensee Representative, Diorena "Rocky" Rock and the reason for the visit was explained. Entrance interview. The LPA and Administrator toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. COMMON AREAS: This includes the family room, den, and dining room. At the time of the visit, furniture in the common areas was observed to be in good condition. The facility maintained a comfortable temperature. Hardwired combination carbon monoxide and smoke detectors and fire door were tested at 10:56 a.m. and all systems were functional at the time of the visit. The fire extinguisher was observed and fully charged on 02/18/2026. The emergency exiting plans/sketch are posted. The emergency telephone numbers are posted in the common hallway. The LPA observed required postings throughout the common space. Activities were observed in the common areas. The fireplace in the living room was adequately screened, covered and is non-functional. There is a functioning telephone on the premises. Auditory alarms at the entrances and exits were observed and functional at the time of the visit. LPA observed surveillance cameras installed in the common areas of the facility. The Administrator stated that the cameras are non-functional at the time however they may be used at a later time. LPA advised Manager and Administrator that if at any time the cameras become functional that none of them can be equipped with audio capability and an update will need to be made on their plan of operation including the cameras and approved by the department. INTERVIEWS: Starting at 10 a.m. and throughout the visit one (1) staff, four (4) resident, and one (1) visitor interviews were conducted. Staff interview revealed that staff are knowledgeable in their job responsibilities, Resident rights, different forms of abuse, and reporting procedures. Resident and visitor interview revealed that no concerns were noted or voiced at the time of the visit. Report Continued on LIC 809-C PAGE 2...
Kasandra Lopez
Erica Mosley
DATE: 10/07/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/07/2026
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 5
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: A LOVING HEART SENIOR CARE
FACILITY NUMBER: 565801597
VISIT DATE: 10/07/2026
NARRATIVE
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(PAGE 2) Report Continued from LIC 809-C...

BEDROOMS: There are six (6) total bedrooms in the facility; six (6) bedrooms are designated as private, single occupancy, resident rooms and one (1) staff rooms. The staff room is kept locked at all times and observed to be occupied by staff. Two (2) out of six (6) resident rooms have exits to the exterior. All passageways were observed to be clear of obstructions. All resident rooms were observed to be furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting.

RESTROOMS: There are two (2) total restrooms. One (1) is designated as a shared / common resident restroom, One (1) is designated as a staff / guest restroom. Resident restroom was observed to be equipped with a slip resistant surface / mat. Grab bars were observed in the restroom. The restroom was sufficiently stocked with supplies and paper towels. The hot water temperature was measured in the resident restroom and measured at 110.2 degrees Fahrenheit, within the required range. LPA observed storage space closets in hallway containing extra clean linens and towels for resident use.

KITCHEN: The LPA inspected the kitchen/food service area. Knives and sharps were observed in a locked drawer. Kitchen appliances were in operable condition. The facility has a sufficient supply of two (2) day perishable and seven (7) day non-perishable food. Refrigerator and food pantry were checked for proper labels and expiration dates. The kitchen faucet was measured for hot water temperature, and it measured 113.2 degrees Fahrenheit. Cleaning supplies and other chemicals are kept locked under the sink inaccessible to residents in care.

GARAGE: The garage is attached to the house. Washer and dryer units are located inside the garage. Emergency water and additional food is located inside the garage. Cleaning solutions, and chemicals are inaccessible and locked away in the garage. LPA observed two (2) additional refrigerators with extra food that were checked for proper labels and expiration dates.

BACKYARD: The entire property is fenced. The backyard and front porch area have a covered patio area with shade, patio furniture including a table and chairs for resident use. LPA observed one (1) self-latching gate. LPA observed a gated pool which was locked and is inaccessible to residents in care at the time of the visit. Only one (1) pathway is used as an emergency exit which was free of obstructions at the time of the visit. Report Continued on LIC 809-C PAGE 3...

NAME OF LICENSING PROGRAM MANAGER: Kasandra Lopez
NAME OF LICENSING PROGRAM ANALYST: Erica Mosley
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/07/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2026
LIC809 (FAS) - (06/04)
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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: A LOVING HEART SENIOR CARE
FACILITY NUMBER: 565801597
VISIT DATE: 10/07/2026
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(PAGE 3) Report Continued from LIC 809-C PAGE 2...
RECORDS: Resident Records: were reviewed beginning at 11 a.m. Four (4) Resident files were reviewed for, but not limited to, the following: signed admission agreements, current medical assessments with TB results, LIC627(c) Consent for Treatment form, and current needs and services plan. LPA observed two (2) out of four (4) files to be complete at the time of the visit. LPA was advised by the Administrator that all the documents were complete but at the time were unavailable at the time. Personnel Records two (2) Personnel files including the Administrator’s file were reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, first aid/CPR training, and the appropriate training.
INFECTION CONTROL/ EMERGENCY DISASTER PLANNING: During today’s visit the LPA reviewed the facility’s infection control plan, practices and the facilities emergency disaster plan. Both documents were observed to be complete and updated annually as required. The facilities policies and procedures, as they pertain to infection control and emergency planning meet the regulatory standard. The last emergency disaster drill took place on 9/24/26 and are conducted quarterly.
MEDICATIONS: Medication review began at approximately 12:15 p.m. Medications are centrally stored and locked in a cabinet in the kitchen adjacent to the dining room. Medications for two (2) residents were reviewed. Medications are labeled and checked for expiration dates. All medications including PRNs were labeled, stored, and locked inaccessible to residents in care. Medications reviewed were found to be self-administered as prescribed. LPA was advised that not all medications are currently documented on the centrally stored medication and destruction record at the time of the visit.
DOCUMENTS: Documents requested during the visit include: LIC 500 facility roster, LIC 9020A Resident roster, a copy of the current Limited Liability insurance, and Emergency disaster plan. Administrator Advised they would email LPA a copy of each document but presented the documents at the time of the visit. At the time if the visit the LPA reviewed the facilities contact information on file including phone numbers, email and annual fees. Administrator confirmed that all information is accurate. Administrator informed LPA they will submit annual fees this week.

The following deficiencies were observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. The Licensee was made aware that failure to correct the deficiencies may result in civil penalties. Exit interview conducted. A copy of the report and appeal rights were provided

NAME OF LICENSING PROGRAM MANAGER: Kasandra Lopez
NAME OF LICENSING PROGRAM ANALYST: Erica Mosley
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/07/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2026
LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 10/07/2026 12:58 PM - It Cannot Be Edited


Created By: Erica Mosley On 10/07/2026 at 12:29 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: A LOVING HEART SENIOR CARE
FACILITY NUMBER: 565801597

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/07/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87506(a)
Resident Records
(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in two (2) out of four (4) resident files were not complete with all the required docuemtns at the time of the visit (Pre-admission and Needs and service plan) which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/16/2026
Plan of Correction
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Administrator agrees to review all resdient files and ensure they are complete by POC due date.
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.
Kasandra Lopez
NAME OF LICENSING PROGRAM MANAGER:
Erica Mosley
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/07/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/07/2026


LIC809 (FAS) - (06/04)
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