<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608905
Report Date: 02/10/2025
Date Signed: 02/10/2025 11:54:55 AM

Document Has Been Signed on 02/10/2025 11:54 AM - 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:MY HOME IIFACILITY NUMBER:
197608905
ADMINISTRATOR/
DIRECTOR:
MARK YULEFACILITY TYPE:
740
ADDRESS:6753 ESTEPA DRIVETELEPHONE:
(661) 219-4906
CITY:TUJUNGASTATE: CAZIP CODE:
91042
CAPACITY: 6CENSUS: 6DATE:
02/10/2025
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:15 AM
MET WITH:Mark Yule- AdministratorTIME VISIT/
INSPECTION COMPLETED:
12:00 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 2/10/25 at 10:15AM Licensing Program Analyst (LPA) Angelica Segovia conducted an unannounced Case Management visit to the facility to check on the resident(s) who were evacuated due to the wildfires that had taken place. LPA was greeted by the caregiver. LPA stated the reason for their visit. Administrator Mark Yule arrived shortly after to assist with today’s visit.

LPA asked for census, staff and resident rosters.

Administrator stated that this facility did not have to be evacuate during the fires. However, the facility did accept a total of one (1) resident who was displaced from the wildfires. Resident 1 (R1) was relocated from Lakeview Hospice which perished due to the wildfires. A physical plant tour was conducted at around 11:00AM to ensure the health and safety of residents.

Sufficient supply of two (2) days perishable and seven (7) days non-perishable foods observed. Emergency food supply located in kitchen. All sharps and toxins observed locked and inaccessible to residents.

Relocated residents: Evacuated resident has been placed in appropriate single room with proper bedding, nightstand, chair, and lighting. LPA observed bedding and furniture in proper condition. Sufficient supplies of hygiene observed for residents. LPA observed R1’s medication and file properly stored in locked cabinet. LPA observed resident in their room watching television.

Fire drill: Last fire drill was conducted 12-01-2024. LPA observed fire extinguisher located near the kitchen and dated 2-10-25. The last annual was completed on 09-10-24. Fire alarms and Carbon Monoxide detectors were last tested on 09-10-24 and noted to be in good condition and working properly. Emergency Disaster Plan for Residential Care Facilities for the Elderly posted immediately upon entrance along with required postings.

No immediate health and safety issues observed. Exist interview conducted and a copy of this report was given to the Administrator.

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Angelica Segovia
LICENSING EVALUATOR SIGNATURE: DATE: 02/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/10/2025
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 1