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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610372
Report Date: 12/11/2025
Date Signed: 12/11/2025 01:45:07 PM

Document Has Been Signed on 12/11/2025 01:45 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:WILLOWVIEW HOME TWO, LLCFACILITY NUMBER:
197610372
ADMINISTRATOR/
DIRECTOR:		ANGUIANO, EMALYNFACILITY TYPE:
740
ADDRESS:44148 12TH ST WESTTELEPHONE:
(661) 418-6180
CITY:LANCASTERSTATE: CAZIP CODE:
93534
CAPACITY: 6CENSUS: 3DATE:
12/11/2025
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Elbert Perez- CaregiverTIME VISIT/
INSPECTION COMPLETED:
03:00 PM
NARRATIVE
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On 12/11/2025 at approximately 09:30 AM, Licensing Program Analyst (LPA), Angelica Segovia conducted a Case Management visit during their initial complaint visit (Control# 31-AS-20251202141313) and the following deficiencies were observed. LPA interviewed and conducted record reviews pertaining to three (3) residents (R1-R3) and one (1) staff member (S2).

Upon LPA’s record review, LPA observed three (3) of the three (3) residents records to be incomplete and not updated. LPA observed three (3) of the three (3) residents to be missing their Needs and Services and Pre-Appraisals. When LPA interviewed S2 and questioned how they are providing care to the residents without knowing what their care plan or needs are, S2 stated that they will review their hospital discharge paperwork and base their care from there forth.

During LPA’s record review of S2’s personnel record, LPA observed S2 First-Aid/Cardiopulmonary Resuscitation (CPR) certificate to be dated 10/12/2022 which was expired. LPA advised S2 to renew their certificate, which they agreed they would do so. LPA could also not locate any training for S2. S2 stated that they are to receive training from the Administrator. Let it be noted that S2 was the only caregiver present during LPA’s visit.

(Continue to 809-C)

NAME OF LICENSING PROGRAM MANAGER: Troy Agard
NAME OF LICENSING PROGRAM ANALYST: Angelica Segovia
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 12/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/11/2025
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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Document Has Been Signed on 12/11/2025 01:45 PM - It Cannot Be Edited


Created By: Angelica Segovia On 12/11/2025 at 12:18 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: WILLOWVIEW HOME TWO, LLC
FACILITY NUMBER: 197610372

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/11/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/25/2025
Section Cited
CCR
87457(c)

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87457 Pre-Admission Appraisal. (c) Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of their individual service needs...

This requirement is not met as evidenced by:
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The Administrator will review the regulation and email LPA Segovia a statement of understanding. Additionally, the Administrator will email LPA Segovia the Pre-Appraisals and Needs/Services for all three residents.
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Based on interviews, record review and observation three of the three residents records were incomplete and not updated: missing their Pre-Appraisal and completed Needs/Services Plan which poses a potential Health, Safety, or Personal Rights risk to persons in care.
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Type B
12/15/2025
Section Cited
HSC1569.618(c)(3)

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(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 evidenced by:
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The Administrator will email LPA Segovia S2's updated first-aid/CPR training certificate
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Based on interviews, record review and observation S2 was missing their current First-Aid/CPR training certificate and was the only staff present which poses a potential Health, Safety or Personal Rights risk to persons in care.
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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:
Angelica Segovia
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 12/11/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/11/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/11/2025 01:45 PM - It Cannot Be Edited


Created By: Angelica Segovia On 12/11/2025 at 12:28 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: WILLOWVIEW HOME TWO, LLC
FACILITY NUMBER: 197610372

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/11/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/25/2025
Section Cited
CCR
87412(c)(1)(A)

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87412 Personnel Records. (c) Licensees shall maintain in the personnel records...(1) The following staff training...shall be documented: (A) For staff...there shall be documentation of... initial training...and annually...This requirement is not met as evidenced by
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The Administrator will email LPA Segovia S2's initial training and current annual training.
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Based on interviews, record review and observations S2 was missing their intital training and annual training which poses a potential Health, Safety, or Personal Rights risk to persons in care.
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Type B
12/25/2025
Section Cited
CCR87303(a)

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87303 Maintenance and Operation. (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include...the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
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The Administrator will email LPA Segovia proof of photos showcasing both gates to be fixed and in good repair.
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Based on observations two gates of the facility are broken which poses a potential Health, Safety, or Personal Rights risk to persons in care.
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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:
Angelica Segovia
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 12/11/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/11/2025


LIC809 (FAS) - (06/04)
Page: 4 of 5
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: WILLOWVIEW HOME TWO, LLC
FACILITY NUMBER: 197610372
VISIT DATE: 12/11/2025
NARRATIVE
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During LPA’s physical plant tour, LPA observed the exit leading to the front of the facility from the backyard to be broken. LPA observed two brown squared nightstand dressers pushed up against an unsecured small white gate being utilized as a form of barrier from the exit to the front driveway. LPA also observed the front fence to be broken with one gate attachment missing. LPA observed an unsecured white small gate and mattresses with a toilet placed in front being used as the replacement of said missing gate.

Citations issued. Please refer to 809-D.

No other immediate health and safety issues observed during the time of visit.

Exit interview conducted, appeal rights given and a copy of this report was provided to the caregiver.

NAME OF LICENSING PROGRAM MANAGER: Troy Agard
NAME OF LICENSING PROGRAM ANALYST: Angelica Segovia
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2025
LIC809 (FAS) - (06/04)
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