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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609899
Report Date: 03/02/2026
Date Signed: 03/02/2026 02:53:18 PM

Document Has Been Signed on 03/02/2026 02:53 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:ARCADY VILLAFACILITY NUMBER:
197609899
ADMINISTRATOR/
DIRECTOR:		CAJAYON, JOJOFACILITY TYPE:
740
ADDRESS:44334 LIVELY AVETELEPHONE:
(818) 913-2188
CITY:LANCASTERSTATE: CAZIP CODE:
93536
CAPACITY: 6CENSUS: DATE:
03/02/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:10 AM
MET WITH:Dulce Villeros - House ManagerTIME VISIT/
INSPECTION COMPLETED:
03:00 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
Licensing Program Analyst (LPA) Evelin Rios arrived to this facility to conducted an Annual Required Inspection visit. When LPA arrived she was greeted by the house manager, Dulce Villeros. Staff contacted the Administrator, Jojo Cajayon and informed him LPA was at the facility. LPA explained the purpose of the visit. Administrator was not able to meet LPA at the facility but would be available by telephone for questions.

At 9:23 AM LPA requested a copy of the facility's Emergency Disaster Plan (LIC610E), Personnel Report (LIC500), Register of Facility Residents (LIC9020) and a copy of the facility's Liability Insurance. LPA obtained copies for review and to update the Regional Office file. At approximately 9:33 AM, LPA initiated the physical plant tour of the facility inside and out. At the entrance, LPA observed required postings on the wall by the front door and a small table with a visitor sign-in along with hand sanitizer.

The facility has an open concept layout that includes the kitchen, living area, and dining area. In the kitchen LPA observed appliances and fixtures were functional. LPA observed two refrigerators stocked with a sufficient supply of two day perishables, and the pantry and kitchen cabinets contained an adequate amount of seven day non perishable food. LPA also observed fresh fruit available in the refrigerator and on the kitchen counter. LPA observed knives and sharps were stored in a locked drawer. LPA observed the cabinet under the kitchen sink was locked and it is used to store cleaning supplies.

In the living area and dining area LPA observed the furniture to be in good repair and sit the capacity of the facility. LPA observed the fire extinguisher on a wall by the dining area. LPA observed one (1) resident in the living room watching television. The fire extinguisher was fully charged and has a last serviced date of 05/16/2025. LPA did not observe tripping hazards. (Continue to LIC809-C)
NAME OF LICENSING PROGRAM MANAGER: Mary G Flores
NAME OF LICENSING PROGRAM ANALYST: Evelin Rios
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 03/02/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/02/2026
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 8
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 8
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: ARCADY VILLA
FACILITY NUMBER: 197609899
VISIT DATE: 03/02/2026
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
(Continued from LIC809)

The backyard has a table with chairs for residents' use. LPA observed the passageway to the exit was clear of obstruction. The backyard has sufficient space for residents. There is no swimming pool or bodies of water. On the side of the house not leading to an exit LPA observed a mattress and other furniture piled on top of each other. According to the administrator they will schedule a bulk pick up to clear the space. LPA observed a locked shed used for storage.

The facility has two (2) bathrooms. The bathrooms are next to each other by bedroom #6. LPA observed that the bathrooms were equipped with functioning plumbing fixtures, required grab bars, non-skid mats and supplied with toilet paper, hand soap and paper towels. LPA measured the hot water temperature in both bathrooms between 9:50 AM and 9:55 AM with readings of 117.2°F and 114.1°F, within regulation.



LPA observed a locked cabinet where centrally stored medication and medication records are stored. leading to the bedrooms. The facility has a fully stocked first aid kit an first aid manual. There are six (6) bedrooms designated for residents. Bedrooms are private. The facility has a fire clearance (STD850) dated 09/10/2019, indicating approval for five (5) non ambulatory residents and one (1) bedridden resident for a total capacity of six (6) residents. Bedrooms designated for residents were furnished with a bed, night stand, chair, dresser, bedding, sufficient lighting and closet space. Doors leading to the outside have auditory alarms there were on and functioning properly during the visit. In bedroom #1 and bedroom #2 LPA observed open windows without a screen.

The facility is equipped with dual carbon monoxide and smoke detectors that are interconnected through out the facility. LPA observed the house manager test a detector at 11:13 AM and it was working properly.

The facility has no garage. The laundry room is maintained locked. In the laundry room LPA observed a washer and dryer. Detergents and cleaning supplies are kept in the laundry room.

There is an office space by the laundry room that has facility, staff, and residents records and is also used for storage of emergency water.

(Con. to LIC809-C) Page 2 of 3
NAME OF LICENSING PROGRAM MANAGER: Mary G Flores
NAME OF LICENSING PROGRAM ANALYST: Evelin Rios
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/02/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2026
LIC809 (FAS) - (06/04)
Page: 3 of 8
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: ARCADY VILLA
FACILITY NUMBER: 197609899
VISIT DATE: 03/02/2026
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
(Continued from LIC809-C)

From 11:22 AM to 1:00 PM, LPA conducted a file review of five (5) resident files to ensure licensing forms were complete and in compliance. LPA's review of resident records revealed three (3) out of five (5) residents, Resident #2 (R2), Resident #4 (R4) and Resident #5 (R5) did not have a signed and dated Resident Appraisal and had blank Appraisal/Needs and Services (LIC625) forms. Appraisals on file were completed as pre admission appraisals. Residents have been in the facility for more than 12 months. LPA's review Physician's bed rail orders do not indicate whether it is for half bed rail or full bed rail for those residents with bed rails on their bed. Administrator will obtain orders that indicate the length of the bed rials. Centrally stored medication and medication records were reviewed for proper storage and documentation.

In addition, LPA also conducted a file review of two (2) staff records to insure training documents are in compliance and complete. LPA did not observed the annual training record for the house manager. According to the house manager and the administrator training had been conducted but training documentation had not been filled out. LPA’s review of the facility’s quarterly emergency drill records, along with an interview with the house manager, revealed that they had not participated in an emergency disaster drill at the facility within the past year.

LPA reviewed the Pending Administrator Certification List and observed Administrator's name on the list.

Pursuant to Title 22 Division 6 of the CA Code of Regulations, there were deficiencies observed during this visit. Refer to LIC809-D. LPA also provided LIC9102TV and LIC9102TA to house manager. Exit Interview was conducted with the Administrator by telephone. Copy of Appeal Rights and a copy of the report provided to the house manger.

Page of 3 of 3

NAME OF LICENSING PROGRAM MANAGER: Mary G Flores
NAME OF LICENSING PROGRAM ANALYST: Evelin Rios
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/02/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2026
LIC809 (FAS) - (06/04)
Page: 4 of 8
Document Has Been Signed on 03/02/2026 02:53 PM - It Cannot Be Edited


Created By: Evelin Rios On 03/02/2026 at 01:55 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: ARCADY VILLA
FACILITY NUMBER: 197609899

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/02/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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
1
2
3
4
Based on interview and record review, the licensee did not comply with the section cited above in three (3) out of five (5) residents not having re appraisals documented which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/13/2026
Plan of Correction
1
2
3
4
The Administrator will conduct re appraisals for Resident #2 (R2), Resident #4 (R4) and Resident #5 (R5) and provide copies to the Department by POC due date 03/13/2026.
Type B
Section Cited
CCR
87421(c)
87421 Personnel Records (c) Licensees shall maintain in the personnel records verification of required staff training and orientation.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on interview and record review, the licensee did not comply with the section cited above in one (1) out of two (2) staff did not have documentation of the required annual training which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/13/2026
Plan of Correction
1
2
3
4
The Administrator will document all staff training and submit proof of completed training to the Department by the POC due date of 03/13/2026.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Mary G Flores
NAME OF LICENSING PROGRAM MANAGER:
Evelin Rios
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 03/02/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/02/2026


LIC809 (FAS) - (06/04)
Page: 5 of 8
Document Has Been Signed on 03/02/2026 02:53 PM - It Cannot Be Edited


Created By: Evelin Rios On 03/02/2026 at 02:21 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: ARCADY VILLA
FACILITY NUMBER: 197609899

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/02/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(c)
1569.695 Emergency Plans (c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.


This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on interview and record review, the licensee did not comply with the section cited above in that the facility failed to conduct an emergency drill at least quarterly for each shift which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/06/2026
Plan of Correction
1
2
3
4
Administrator will conduct a drill for each shift and documentation of the drill shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. The documentation will be submitted to the Department by POC due date 03/06/2026.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Mary G Flores
NAME OF LICENSING PROGRAM MANAGER:
Evelin Rios
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 03/02/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/02/2026


LIC809 (FAS) - (06/04)
Page: 8 of 8