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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610011
Report Date: 01/16/2026
Date Signed: 01/16/2026 12:16:18 PM

Document Has Been Signed on 01/16/2026 12:16 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:MASCHELLE VILLAFACILITY NUMBER:
197610011
ADMINISTRATOR/
DIRECTOR:		LEBORA D NAKAHARAFACILITY TYPE:
740
ADDRESS:25577 ALMENDRA DRIVETELEPHONE:
(661) 425-7500
CITY:VALENCIASTATE: CAZIP CODE:
91355
CAPACITY: 6CENSUS: 4DATE:
01/16/2026
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Micaela BaliwagTIME VISIT/
INSPECTION COMPLETED:
12:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Abeye Duguma met with Micaela Baliwag for a Required One (01) Year visit. LPA explained the reason for the visit and a tour of the physical plant was conducted at around 10:00 AM and the following was noted:

The facility has outdoor furniture with a covered shaded area for residents and visitors. The facility does not have a swimming pool/body of water.

The facility has a total of four (04) bedrooms and two (02) bathrooms. The facility is fire cleared for six (06) non-ambulatory of which one (01) may be bedridden and approved for one (01) hospice. The facility is currently occupying four (04) residents.

Kitchen is sufficiently stocked with at least two (02) days perishable and seven (07) days non-perishable food. Frozen foods are wrapped and stored appropriately. Food storage and preparation areas are clean and inaccessible to pests.

Knives and sharps are observed to be locked and inaccessible to residents. Laundry detergents, cleaning agents and other toxins are locked away.

(continued on LIC 809-C)
NAME OF LICENSING PROGRAM MANAGER: Troy Agard
NAME OF LICENSING PROGRAM ANALYST: Abeye Duguma
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 01/16/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/16/2026
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: MASCHELLE VILLA
FACILITY NUMBER: 197610011
VISIT DATE: 01/16/2026
NARRATIVE
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The living and dining room are neat and clean. The facility temperature was set to 65°F. The smoke and carbon monoxide detectors are hardwired, interconnected and observed to be operational. Fire extinguisher is located near the kitchen and observed to be fully charged and last inspected 10/22/2025.
The residents' rooms are adequately furnished with appropriate lighting system. Hallways are well lit. Residents have enough personal hygiene product provided by the licensee. The bathroom was checked for cleanliness and proper operations. The hot water temperature was measured at 148.2°F. Towels and washcloths are not shared. There was enough clean linen available in the cabinets.

LPA observed medication to be locked and inaccessible to residents. Facility maintains a complete first aid kit.

Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 9099-D):

No other health and safety hazards noted during the visit.

Exit interview conducted. Copy of this report issued.

NAME OF LICENSING PROGRAM MANAGER: Troy Agard
NAME OF LICENSING PROGRAM ANALYST: Abeye Duguma
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 01/16/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/16/2026
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/16/2026 12:16 PM - It Cannot Be Edited


Created By: Abeye Duguma On 01/16/2026 at 11:51 AM
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: MASCHELLE VILLA
FACILITY NUMBER: 197610011

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/16/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(b)(1)


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observations, the licensee did not comply with the section cited above as the thermostat was set to 65 degrees and the temperature at the time was 66 degrees, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/18/2026
Plan of Correction
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Licensee will review regulation and submit a written letter to the LPA by the POC due date stating they have read, understood and will ensure to follow the regulations going forward. LPA also had staff adjust temperature before departure.
Type B
Section Cited
CCR
87303(e)(2)


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observations, the licensee did not comply with the section cited above as the hot water temperature was 148.2 at the time of inspection, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/18/2026
Plan of Correction
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Licensee will review regulation and submit a written letter to the LPA by the POC due date stating they have read, understood and will ensure to follow the regulations going forward. LPA also had staff adjust temperature before departure.
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:
Abeye Duguma
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 01/16/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/16/2026


LIC809 (FAS) - (06/04)
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