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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609015
Report Date: 12/16/2025
Date Signed: 12/16/2025 05:03:32 PM

Document Has Been Signed on 12/16/2025 05:03 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:CARING HEARTS SENIOR CARE HOME LLCFACILITY NUMBER:
197609015
ADMINISTRATOR/
DIRECTOR:		AMORSOLO-SAMANIEGO, MARITAFACILITY TYPE:
740
ADDRESS:4144 VAHAN COURTTELEPHONE:
(661) 794-9940
CITY:LANCASTERSTATE: CAZIP CODE:
93536
CAPACITY: 6CENSUS: DATE:
12/16/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:40 PM
MET WITH:Marita Amorsolo-SamaniegoTIME VISIT/
INSPECTION COMPLETED:
05:15 PM
NARRATIVE
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On 12/16/2025 at 1:40 p.m., Licensing Program Analyst (LPA) Evelin Rios arrived to this facility to conduct an unannounced, annual inspection. LPA was greeted by Staff #1(S1), who granted access. S1 contacted the administrator, Marita Amorsolo-Samaniego. Another staff, Staff #2 (S2) was observed by LPA in the facility assisting residents. The administrator and designee, Tatiana Buendia arrived shortly after. The administrator could not stay for the duration of the visit and designated, Tatiana to sign todays report. By the entrance LPA observed that the facility had required postings, which include but are not limited to the Complaint Poster, Long-Term Care Ombudsman information, and Residents' Rights.

At approximately 2:00 p.m., LPA conducted an inspection of the facility inside and out and the following was observed:

Common Areas: These include the sitting area at the front of the facility, and the living/dining area. The sitting area, living/dining area were clean and clear of clutter, furnished appropriately and sit the capacity of the facility. The furniture was observed to be in good repair.

Bedrooms: There are five (5) bedrooms designated for residents. One (1) bedroom is shared. LPA observed each resident room to be properly furnished and have sufficient storage. Exit doors had auditory alarms that were on and observed functioning.

The facility is equipped with hardwired smoke and carbon monoxide detectors through out the facility. LPA observed S2 test detectors at approximately 2:11 p.m. and were observed to be functioning.
(Continued on LIC809-C)
NAME OF LICENSING PROGRAM MANAGER: Nichelle Gillyard
NAME OF LICENSING PROGRAM ANALYST: Evelin Rios
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 12/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/16/2025
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: CARING HEARTS SENIOR CARE HOME LLC
FACILITY NUMBER: 197609015
VISIT DATE: 12/16/2025
NARRATIVE
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(Continued from LIC809)Bathrooms: The facility has three (3) bathrooms, two of which are designated for resident use, and one is located in the shared bedroom for private use. Bathrooms were properly supplied with hand soap, toilet paper and paper towels. Hot water temperature in the bathrooms were tested at 2:16 p.m. and measured around 116.8 degrees Fahrenheit.

Laundry Room: The laundry room was observed locked. Cleaning supplies and detergents were observed locked in cabinets in the laundry room.

Kitchen: The kitchen was observed clean and clear of clutter. Fixtures and appliances were observed functional. LPA observed a sufficient amount of 2-days perishable and 7-days non-perishable food in the facility. Food was observed stored in covered containers at appropriate temperatures. Knives were observed locked in a kitchen drawer. Centrally stored medication was observed locked in a kitchen cabinet. A fully charged fire extinguisher was observed on a kitchen wall with purchase date 03/19/2024. LPA observed a fully stocked first aid kit and manual accessible to staff in the kitchen.

Surrounding Grounds: Backyard space was large enough for outdoor activities. The backyard is fully fenced in and no hazards observed. No body of waters observed.

Client/Staff Records: At approximately 3:00 p.m., LPA reviewed the facility’s file, as well as resident and staff records, to assess compliance with required licensing documentation. Facility’s file, included the but not limited to, resident roster, personnel report, liability insurance certificate, emergency and disaster plans, and documentation of emergency drills conducted by the facility. At approximately 3:17 p.m., LPA reviewed five (5) resident records and three (3) staff records. During the review of Resident #1’s (R1) Physician’s Report, LPA observed that TB test results were not documented. According to designee the facility is awaiting a mobile lab to schedule an in-home TB test for R1. No documentation of TB test results was found in R1’s file at the time of the visit.

Deficiency observed during the visit (refer to LIC809-D). Appeal Rights Provided. Exit Interview conducted. A copy of the report issued.
NAME OF LICENSING PROGRAM MANAGER: Nichelle Gillyard
NAME OF LICENSING PROGRAM ANALYST: Evelin Rios
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/16/2025 05:03 PM - It Cannot Be Edited


Created By: Evelin Rios On 12/16/2025 at 04:48 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: CARING HEARTS SENIOR CARE HOME LLC
FACILITY NUMBER: 197609015

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/16/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87458(c)(1)(A)
Medical Assessment
(c) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the licensed medical professional's diagnosis or diagnoses and results of an examination for all of the following: (A) Communicable tuberculosis.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review and interview, the licensee did not comply with the section cited above in one out of 6 resident, Resident #1 (R1) not having a TB test with results documented on file which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/02/2026
Plan of Correction
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Facility will provide TB results for R1 to LPA by POC due date 01/02/2026.
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.
Nichelle Gillyard
NAME OF LICENSING PROGRAM MANAGER:
Evelin Rios
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 12/16/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/16/2025


LIC809 (FAS) - (06/04)
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