197609821-11-14-2025-31-AS-ERIS-DNES2B-20251114122916

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609821
Report Date: 11/14/2025
Date Signed: 11/14/2025 12:29:22 PM

Document Has Been Signed on 11/14/2025 12:29 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:	A HOME FOR YOU		FACILITY NUMBER:	197609821
ADMINISTRATOR/ DIRECTOR:	NEPOMUCENO, MERLITA		FACILITY TYPE:	740
ADDRESS:	43845 GENERATION AVE		TELEPHONE:	(818) 357-8667
CITY:	LANCASTER	STATE: CA	ZIP CODE:	93536
CAPACITY: 6		CENSUS: 4	DATE:	11/14/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:50 AM
MET WITH:	Merlita Nepomuceno - Administrator		TIME VISIT/ INSPECTION COMPLETED:	12:40 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 11/14/2025 Licensing Program Analyst (LPA) Evelin Rios arrived at the facility to conduct an unannounced annual inspection. Upon entry, LPA was asked to sign in and had their temperature taken by staff. LPA was greeted by the Administrator Merlita Nepomuceno. LPA Rios explained the purpose of the visit. At 9:00 a.m., LPA and Administrator conducted a physical plant tour of the facility, both inside and outside. The following observations were made: LPA observed required postings were displayed on the walls leading to the common areas. A closet by the entrance was observed containing emergency food and water, a fully stocked first aid kit, flashlights, and an overflow supply of pantry food. The attached garage is through a staff room that is maintained locked. Inside the attached garage, LPA observed a washer and dryer, a locked cabinet containing cleaning products and chemicals, and a deep freezer with an overflow supply of food. In the kitchen, LPA observed the appliances and fixtures were in good working condition. LPA observed a sufficient supply of two days perishable food and seven days non-perishable food. Cookware, cutlery, and dishware were observed to be in good repair. Residents' medications were observed locked in a kitchen cabinet. On a kitchen wall LPA observed a fire extinguisher, fully charged with purchased date 09/01/2025. A carbon monoxide detector located by the kitchen was tested by staff and was observed operational.

NAME OF LICENSING PROGRAM MANAGER: Nichelle Gillyard
NAME OF LICENSING PROGRAM ANALYST: Evelin Rios
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 11/14/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2025

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 3

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)

Page: 2 of 3

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: A HOME FOR YOU	FACILITY NUMBER: 197609821
	VISIT DATE: 11/14/2025

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
26
27
28
29
30
31
32

There are four (4) bedrooms designated for residents' use. One (1) room is shared. Resident bedrooms were furnished with beds, night stand, chairs, dressers, bedding and linens. The bedrooms have sufficient lighting and storage. Exit doors with auditory alarms were observed operational.

There are two (2) bathrooms designated for residents. One (1) bathroom is located in the shared room and is for private use. Bathrooms were properly supplied and had functional fixtures. Hot water temperature was taken from one (1) of two (2) bathrooms at 10:58 a.m. and read 113 degrees Fahrenheit, within regulation.

The common areas, include the living and dining rooms. They were clean, clear of clutter, and appropriately furnished. The furniture was observed to be in good repair. A fireplace in the living room was secured with a screen. A telephone was accessible to residents on the kitchen peninsula and a television along with games were readily available for resident use. No tripping hazards were observed.

The outdoor area was free of hazards and has a covered patio with outdoor furniture. LPA observed a locked shed used for storage. Passageways to the emergency exit was free from obstructions.

The smoke detectors are interconnected. LPA observed a staff test a smoke detector at 11:02 a.m. The smoke detector alarms went off through out the facility.

LPA reviewed facility records, including but not limited to the Certificate of Liability Insurance, the Infection Control Plan (last reviewed by the licensee representative on 07/31/2025), the Emergency and Disaster Plan (LIC 610E, reviewed on 10/02/2025). From approximately 9:30 a.m. to 11:00 am., LPA reviewed staff files and resident records. LPA conducted a file review of three (3) staff records to insure forms and training are up to date and compliance with licensing forms. LPA conducted a file review of four (4) resident records to insure compliance of licensing forms. LPA and administrator reviewed centrally stored medication and medication records for proper documentation. Facility also keeps a Medication Administration Record (MAR).

Pursuant to Title 22, Division 6, Chapter 8 of the CA Code of Regulations, there were no deficiencies observed during todays visit. 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: 11/14/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2025

LIC809 (FAS) - (06/04)

Page: 3 of 3