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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610326
Report Date: 02/28/2026
Date Signed: 02/28/2026 03:23:55 PM

Document Has Been Signed on 02/28/2026 03:23 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:MONDELL PINE MANOR IIFACILITY NUMBER:
197610326
ADMINISTRATOR/
DIRECTOR:		ROCELA MOLINAFACILITY TYPE:
740
ADDRESS:39040 MONDELL PINE AVENUETELEPHONE:
(661) 480-5023
CITY:PALMDALESTATE: CAZIP CODE:
93551
CAPACITY: 6CENSUS: 5DATE:
02/28/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:14 PM
MET WITH:Richard Garcia - House managerTIME VISIT/
INSPECTION COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) Jose Tan conducted an unannounced visit and was greeted by the staff Renante Cuenca who called the Administrator. House Manager Richard Garcia arrived five (5) minutes later. LPA explained the reason for the visit. The facility is fire cleared for six (6) non-ambulatory residents, two (2) of which may be bedridden.

At 12:22 PM, LPA conducted the physical plant tour with the House manager and observed the following:

The facility is a single storey with four (4) bedrooms and three (3) bathrooms. An additional bedroom located in the garage was designated for staff use only. Dual smoke and carbon monoxide alarms were tested and observed to be operable. The facility is equipped with sprinkler system.

Common Areas – The family room, dining room, and kitchen are combined. The family room was furnished with comfortable seating and a television. The dining room contained a dining room table and chairs. Fire extinguishers were located near the kitchen and the main door upon entry and last inspected on 11/14/25.

Medications: LPA observed the resident medications, first aid kit, and PPE supplies were safely locked in a kitchen cabinet.
Kitchen – LPA observed a two day supply of perishable food and a seven day supply of non-perishable food items. Dishwashing liquid and other cleaning agents were observed locked underneath the kitchen sink.
Laundry Room – The laundry room door has a key-punch lock system and was observed to be locked during visit. Laundry detergent and other toxins were locked in the laundry room.
NAME OF LICENSING PROGRAM MANAGER: Troy Agard
NAME OF LICENSING PROGRAM ANALYST: Jose Gary Tan
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 02/28/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/28/2026
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.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: MONDELL PINE MANOR II
FACILITY NUMBER: 197610326
VISIT DATE: 02/28/2026
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(continued from LIC 809)

Garage - The garage was attached to the house and can only enter through the locked laundry room. The staff room is located within the garage area.

Resident Rooms: There are four resident rooms which were furnished with a bed, linens, night stand, lamp and chair. The rooms were properly furnished and observed to be neat and clean.

Bathrooms: There are three bathrooms in the facility. The bathrooms contained hand soap, paper towels, grab bars, and slip resistant mats. LPA observed the clean linens were located in a cabinet within the staff bathroom. Water Temperature: was tested and measured at a range of 107.9°F to 111.8°F.

Surrounding Grounds: There were no visible hazards, and passageways were free from obstruction. The side gate of the house was closed and was not locked. There is a shaded area with comfortable seating in backyard.

Client records: Client records are reviewed. Client records appeared to be complete and updated. Staff records: LPA conducted a complete file review of staff record. Staff records appeared to be complete and updated.



Disaster drill was last conducted on 01/10/2026. Required posting are observed to be complete and current and displayed properly at the facility.

Exit interview conducted. Copy of this report issued
NAME OF LICENSING PROGRAM MANAGER: Troy Agard
NAME OF LICENSING PROGRAM ANALYST: Jose Gary Tan
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 02/28/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/28/2026
LIC809 (FAS) - (06/04)
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