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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608907
Report Date: 10/08/2025
Date Signed: 10/08/2025 02:41:19 PM

Document Has Been Signed on 10/08/2025 02:41 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:COMPASSIONATE ELDERLY CARE MANAGEMENT SYSTEMS, INCFACILITY NUMBER:
197608907
ADMINISTRATOR/
DIRECTOR:		CELIA T. OYIBUFACILITY TYPE:
740
ADDRESS:44161 11TH ST. WTELEPHONE:
(661) 317-7354
CITY:LANCASTERSTATE: CAZIP CODE:
93534
CAPACITY: 6CENSUS: 6DATE:
10/08/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Celia Oyibu- AdministratorTIME VISIT/
INSPECTION COMPLETED:
03:00 PM
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On 10/08/2025 at approximately 09:30 AM, Licensing Program Analyst (LPA), Angelica Segovia conducted an unannounced annual visit to the facility. LPA was greeted by the caregiver and stated the reason for their visit. The Administrator, Celia Oyibu arrived shortly after to assist with today’s visit.

LPA asked for the census, Staff/Resident Roster, and Liability Insurance. LPA conducted a physical plant tour at approximately 12:00 PM and the following was noted:

The facility is a single-story building with four (4) bedrooms and two (2) bathrooms. The facility is currently occupying six (6) residents. There is a designated staff room. One (1) room and one (1) bathroom is designated for staff use only. The facility has an approved fire clearance for two (2) non-ambulatory residents of which one (1) may be bedridden. Hospice waiver approved for two (2).

Common areas: The living room and dining room were observed to be neat, clean, and organized. The rooms were observed to be properly furnished and in good repair. The facility maintains a comfortable temperature at 74°F. LPA observed a fire extinguisher to be located near the kitchen. LPA observed required postings such as Long-Term Care Ombudsman, Emergency Disaster Plan, and Personal Rights to be located alongside the entrance. A working telephone was observed. LPA observed the fireplace to be covered and inaccessible to residents.

Kitchen: The kitchen was observed to be clean and free from pests. Sufficient supplies of seven (7) day nonperishable foods and two (2) day perishable foods were observed. The cleaning solutions/toxins along with the knives/sharps were observed to be kept locked underneath the kitchen sink. Kitchen appliances were observed to be working and in proper condition. (continued on LIC 809-C)

NAME OF LICENSING PROGRAM MANAGER: Troy Agard
NAME OF LICENSING PROGRAM ANALYST: Angelica Segovia
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 10/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/08/2025
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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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: COMPASSIONATE ELDERLY CARE MANAGEMENT SYSTEMS, INC
FACILITY NUMBER: 197608907
VISIT DATE: 10/08/2025
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Laundry Room: The Laundry room was observed to be located near the kitchen. LPA observed cleaning solutions and toxins stored appropriately within the laundry room and inaccessible to residents. The laundry appliances were observed to be working and in proper condition.

Bedrooms: The residents’ rooms are adequately furnished with appropriate furniture and lighting system. Hallways/passageways are lighted appropriately. Extra linens/covers were observed to be stored in cabinets located within the hallway’s passageway.

Bathrooms: The bathrooms were checked for cleanliness and proper operation. The hot water temperature of the staff bathroom was not measured within regulations. LPA observed appropriate grab rails and slip-resistant mats to be in proper condition.

Backyard: The backyard of the facility is equipped with a designated shaded area with outdoor furniture for residents. LPA observed there to be a locked shed. There is no body of water located at the facility.

Garage: The garage is located outside in the backyard and can be accessed from inside the designated staff room. The garage was observed to be kept locked and used for storage purposes. Extra refrigerator and freezer with additional food for residents was observed.

Medications: The medications along with staff and residents’ files were observed to be kept in a locked filing cabinet located in the hallway’s passageway. First-aid kit observed to be equipped with but not limited to bandages, scissors, digital thermometer and tweezer..

Smoke detectors and carbon monoxide observed to be working properly and were tested.

Residents/Staff Records: LPA conducted a complete file review of resident records. Resident records were not complete and updated. Staff records: LPA conducted a complete file review of two (2) staff records. Staff records appeared to be complete and updated.

Let it be noted that this facility will be going through construction/renovations. The renovations will be taking place through the grant funding of Community Care Preservation Project overseen by the Los Angeles County Department of Mental Health (DMH). The Administrator has begun the process with Community Care Licensing Division in developing and submitting their Plan due to all six (6) residents needing to be relocated until renovations have been completed.

(Continue to LIC 809-C)

NAME OF LICENSING PROGRAM MANAGER: Troy Agard
NAME OF LICENSING PROGRAM ANALYST: Angelica Segovia
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/08/2025
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 S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: COMPASSIONATE ELDERLY CARE MANAGEMENT SYSTEMS, INC
FACILITY NUMBER: 197608907
VISIT DATE: 10/08/2025
NARRATIVE
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The following deficiencies were observed during the day of inspection:

-3 of 6 residents missing their Re-Appraisal, 2 out of 6 residents missing their Pre-Appraisal, 2 of 2 residents medications checked were not updated correctly on their medication log. 4 out of 6 residents are noted to be non-ambulatory on their Physician Reports.
Citations issued, please refer to 809-D. A $500 immediate civil penalty for a fire clearance violation was assessed. The administrator was notified that additional civil penalties would be issued if the violations are not corrected by the POC due date.

There were no other immediate health and safety hazards observed during the day of inspection.

Exit interview conducted, Appeal rights given and a copy of this report was provided to the Administrator.

NAME OF LICENSING PROGRAM MANAGER: Troy Agard
NAME OF LICENSING PROGRAM ANALYST: Angelica Segovia
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/08/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/08/2025 02:41 PM - It Cannot Be Edited


Created By: Angelica Segovia On 10/08/2025 at 02:14 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., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: COMPASSIONATE ELDERLY CARE MANAGEMENT SYSTEMS, INC
FACILITY NUMBER: 197608907

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/08/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Request Denied: Appeal Not Submitted Timely
Type A
Section Cited
CCR
87202(a)
Fire Clearance
(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above in 4 out of 6 residents were documented to be non-ambulatory/bedridden on their Physician Reports which is not current with their fire clearance which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/09/2025
Plan of Correction
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The Licensee will email LPA Segovia the Physician Report for R5 for non-ambulatory to ambulatory due Physician Report. Additionally, licensee will email LPA Segovia the process with the fire department regarding their fire clearance violation.
Type A
Section Cited
CCR
87465(a)(6)
Incidental Medical and Dental Care Services
(6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above in 2 of 2 residents medications checked were not updated correctly on their medication log which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/09/2025
Plan of Correction
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The Licensee will review the entire regulation and email LPA Segovia a statement of understanding.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Troy Agard
NAME OF LICENSING PROGRAM MANAGER:
Angelica Segovia
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/08/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/08/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/08/2025 02:41 PM - It Cannot Be Edited


Created By: Angelica Segovia On 10/08/2025 at 02:14 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., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: COMPASSIONATE ELDERLY CARE MANAGEMENT SYSTEMS, INC
FACILITY NUMBER: 197608907

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/08/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87456(a)(2)
Evaluation of Suitability for Admission
(a) Prior to accepting a resident for care and in order to evaluate his/her suitability, the facility shall, as specified in this article 8: (2) Perform a pre-admission appraisal.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above in 2 out of 6 residents were missing their Pre-Appraisal which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/22/2025
Plan of Correction
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The Licensee will email LPA Segovia the Pre-Appraisal for both residents.
Type B
Section Cited
CCR
87463(a)
Reappraisals
(a) The pre-admission appraisal, as specified in Section 87457, Pre-Admission Appraisal, shall be updated, in writing as frequently as necessary or once every 12 months, whichever occurs first, to note significant changes in condition, as defined in Section 87101, Definitions, and to keep the appraisal accurate. For the purposes of this section, the updated pre-admission appraisal shall be referred to as the reappraisal.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above in 3 out of 6 residents were missing their Re-Appraisal which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/22/2025
Plan of Correction
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The Licensee will email LPA Segovia the Re-Appraisal for all three residents.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Troy Agard
NAME OF LICENSING PROGRAM MANAGER:
Angelica Segovia
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/08/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/08/2025


LIC809 (FAS) - (06/04)
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