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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850557
Report Date: 09/23/2026
Date Signed: 09/23/2026 05:00:55 PM

Document Has Been Signed on 09/23/2026 05:00 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:NAVITA RESIDENCES ASHWOODFACILITY NUMBER:
565850557
ADMINISTRATOR/
DIRECTOR:		VIJAYAKUMAR,KARTHIGAFACILITY TYPE:
740
ADDRESS:390 N ASHWOOD AVETELEPHONE:
(805) 620-0187
CITY:VENTURASTATE: CAZIP CODE:
93003
CAPACITY: 6CENSUS: 6DATE:
09/23/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:30 AM
MET WITH:TIME VISIT/
INSPECTION COMPLETED:
05:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Esther Cortez arrived at the facility unannounced to conduct a required annual visit. LPA initially met with Administrator Karthiga Vijayakumar and explained the reason for the visit.

Record Review: At 10:35 a.m. a review of facility files was initiated. The LPA reviewed an Infection Control Plan, Emergency Disaster Plan, and last emergency drill (conducted on 06/30/26). The LPA obtained a Client Roster and Staff Roster. The LPA reviewed five (5) out of six (6) resident files and five (5) out of seven (7) staff files. Records were reviewed for documents including, but not limited to: health screening, TB test, staff training records, fingerprint clearance, resident physician's report, needs and service appraisal, and personal rights. The following was observed: Three residents did not have an Emergency Medical Treatment consent form (LIC627C) on file. At 1:38 p.m. the LPA observed Resident 1 (R1) sitting with a gait belt on, R1 was not able to release the gait belt on their own. Facility did not have an exception on file for R1's gait belt. Otherwise, all other resident and staff files were complete and current.

MEDICATION REVIEW: Medications for two (2) residents were reviewed. Medications were observed stored in a locked cabinet. During Resident's 1 (R1's) audit the Centrally Stored Medication and Destruction Record (CSMDR) was missing start dates for several current medications. R1 had a prescription fro Fish oil 1200mg but was being given Omega-3 instead as staff revealed they thought it was the same. Facility had Docusate sodium 100 mg and Tizanidine 2mg on hand for R1 but did not have discontinued orders and had not destroyed medication. R2's medication audit did not have any errors observed.

Report will continue on LIC809-C, 2nd page.
Kasandra Lopez
Esther Cortez
DATE: 09/23/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/23/2026
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 7
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: NAVITA RESIDENCES ASHWOOD
FACILITY NUMBER: 565850557
VISIT DATE: 09/23/2026
NARRATIVE
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The LPA along with the Administrator toured the facility inside and outside to ensure resident health and safety and the facility is in compliance with Title 22 regulation. The smoke alarms and carbon monoxide detectors were tested and functioned properly. The fire extinguishers were purchased on 7/14/2026 and appeared fully charged.

BEDROOMS: The facility has seven (7) bedrooms total, one (1) of which is designated for staff use and six (6) are private resident rooms. All resident bedrooms were observed to contain a bed, chair, bedside table, dresser, and lighting. All resident rooms had appropriate bedding. There is an ample supply of linens and towels stored in the cabinets in the hallway. Bedrooms containing exit doors had functional auditory alarms. All residents have a wearable pendant to utilize when staff assistance is needed.

RESTROOMS: The facility has three (3) full bathrooms for resident and staff use and one half bath located at the entry. All restrooms contained grab bars and slip-resistant surfaces. Hot water was measured within the required range.

COMMON AREAS: Paint, windows, blinds, and floors are in good repair. The common living and dining areas are clean and properly furnished. A working telephone is present. There is one (1) fireplace in the residence, which was properly screened at the time of the visit. Chemicals are stored in a locked cabinet in the laundry room and in the locked garage.



OUTDOOR SPACE: Building and grounds are free from hazard. Patio area observed with outdoor shaded seating area for resident use. The one (1) outdoor exit gate was observed to be self-closing and self-latching.

KITCHEN: The kitchen contained a sufficient supply of dishes, glasses and utensils. The facility has a sufficient supply of non-perishable food, perishable food and an emergency supply of water is present. Knives are stored in a locked cabinet. Cleaning supplies were observed locked in a cabinet under the sink.

INTERVIEWS: LPA interviewed two (2) residents and two (2) staff. No concerns noted.

Pursuant to Title 22 of the CA Code of Regulations and/or CA Health and Safety Code, the following deficiency was cited (refer to LIC 809-D). Exit interview conducted and copy of the report and appeal rights were provided

NAME OF LICENSING PROGRAM MANAGER: Kasandra Lopez
NAME OF LICENSING PROGRAM ANALYST: Esther Cortez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/23/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2026
LIC809 (FAS) - (06/04)
Page: 7 of 7
Document Has Been Signed on 09/23/2026 05:00 PM - It Cannot Be Edited


Created By: Esther Cortez On 09/23/2026 at 04:19 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. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: NAVITA RESIDENCES ASHWOOD
FACILITY NUMBER: 565850557

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/23/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(a)(4)
Incidental Medical and Dental Care Services
(4) The licensee shall assist residents with self-administered medications as needed.

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 as staff was giving R1 omega-3 instead of their prescribed fish oil, and not accurately documenting medication on the Centrally Stored Medication and Destruction record which posed a potential health, safety or personal rights risk to persons in care
POC Due Date: 09/29/2026
Plan of Correction
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Administrator agreed to conduct a medication audit and ensure the CSMDR is accurately documented for all residents, will ensure to get the correct medication for R1 and notify R1's physician of the incident. Will submit proof all has been completed by 09/29/26.
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:
Esther Cortez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/23/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/23/2026


LIC809 (FAS) - (06/04)
Page: 3 of 7
Document Has Been Signed on 09/23/2026 05:00 PM - It Cannot Be Edited


Created By: Esther Cortez On 09/23/2026 at 04:28 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: NAVITA RESIDENCES ASHWOOD
FACILITY NUMBER: 565850557

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/23/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87608(a)(2)
87608(a)(2) Postural Supports. Postural supports shall be fastened/tied in a manner that permits quick release by the resident.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above in one resident that was left sitting down watching TV with their gait belt and resident is not able to self-release which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/29/2026
Plan of Correction
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Gait belt was taken off the resident while they were seated during the visit. Administrator will discuss with resident, their responsible party, doctor, and submit an exception request if needed. Staff will receive training on resident's personal rights and postural supports. Training will be submitted by 09/29/26.
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:
Esther Cortez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/23/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/23/2026


LIC809 (FAS) - (06/04)
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