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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610242
Report Date: 06/20/2025
Date Signed: 06/20/2025 03:56:01 PM

Document Has Been Signed on 06/20/2025 03:56 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.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:PROVIDENCE MANOR, LLC, THEFACILITY NUMBER:
197610242
ADMINISTRATOR/
DIRECTOR:		DE LIMA, MARY ANN NFACILITY TYPE:
740
ADDRESS:3434 TAMARISK DRIVETELEPHONE:
(661) 526-4322
CITY:PALMDALESTATE: CAZIP CODE:
93551
CAPACITY: 6CENSUS: 5DATE:
06/20/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Mary Ann De LimaTIME VISIT/
INSPECTION COMPLETED:
02:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Melissa Spaeth conducted an unannounced required annual visit and was greeted by two staff members. The Licensee, Mary Ann De Lima arrived at 10:40 am. The facility is licensed to serve six residents of which six may be non-ambulatory and one may be bedridden in any of the bedrooms and there is a hospice waiver for six.

LPA Spaeth reviewed the residents files at 10:30 am until 11:30 am. LPA reviewed staff files at 11:45 am until 12:15 pm. LPA observed two staff members' CPR/First Aid training had expired.

LPA Spaeth and the Administrator toured the facility at 12:00 pm until 12:30 pm. LPA Spaeth observed the facility was neat and clean.

Kitchen – LPA observed a seven-day supply of non-perishable food and a two day supply of perishable food items. LPA observed the cleaning supplies were securely locked underneath the kitchen sink and the knives were locked in a kitchen drawer. The medications are locked in a kitchen cabinet and LPA also observed the first aid kit. A fire extinguisher is also located in the kitchen area.

Continued on 809-C
NAME OF LICENSING PROGRAM MANAGER: Troy Agard
NAME OF LICENSING PROGRAM ANALYST: Melissa Spaeth
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 06/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/20/2025
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 4
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.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: PROVIDENCE MANOR, LLC, THE
FACILITY NUMBER: 197610242
VISIT DATE: 06/20/2025
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Backyard – LPA Spaeth observed the delayed egress alarm leading out of the sliding glass door to the backyard was properly working. The backyard is a shaded area which contained comfortable seating. The side gate leading from the backyard to the front yard was not locked.

Bedrooms – LPA Spaeth observed there is one resident living in the master bedroom. The delayed egress alarm leading from the bedroom to the backyard was properly working. The room contained bed, linens, night stand, and night lamp. LPA also observed the other three bedrooms were finished.

Water Temperature - The water temperature was tested at 12:05 pm and was 105 degrees F.

Bathrooms – LPA Spaeth observed both bathrooms contained slip resistant mats, hand soap, paper towels, grab bars, and trash can.

Common Areas – LPA observed comfortable seating in the living room and family room. The dining area contained a dining room table and chairs.

Smoke/Carbon Monoxide Detectors -The smoke/carbon monoxide detector was tested at 12:30 pm and was operable.

Pursuant to Title 22, California Code of Regulations, one deficiency will be cited (refer to LIC 9099-D.

Exit interview conducted, appeal rights discussed, and a copy of the report was given.

NAME OF LICENSING PROGRAM MANAGER: Troy Agard
NAME OF LICENSING PROGRAM ANALYST: Melissa Spaeth
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2025
LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 06/20/2025 03:56 PM - It Cannot Be Edited


Created By: Melissa Spaeth On 06/20/2025 at 12:52 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: PROVIDENCE MANOR, LLC, THE
FACILITY NUMBER: 197610242

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/20/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.618(c)(3)
Other Provisions
(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's review of staff files, the licensee did not comply with the section cited above in two out of four staff members which poses an immediate health, safety or personal rights risk to persons in care.



















Based upon LPA's review of the staff records, the licensee did not comply with the section cited above in two out of four staff which could pose a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/24/2025
Plan of Correction
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The Licensee will send a snapshot of the staff members' certificate which states the staff members completed the training.
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.
Troy Agard
NAME OF LICENSING PROGRAM MANAGER:
Melissa Spaeth
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/20/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/20/2025


LIC809 (FAS) - (06/04)
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