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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610381
Report Date: 05/30/2025
Date Signed: 05/30/2025 03:33:06 PM

Document Has Been Signed on 05/30/2025 03:33 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
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:RAYWOOD VILLA INCFACILITY NUMBER:
197610381
ADMINISTRATOR/
DIRECTOR:		FONSECA, JASONFACILITY TYPE:
740
ADDRESS:42659 RAYWOOD DRIVETELEPHONE:
(562) 481-6306
CITY:LANCASTERSTATE: CAZIP CODE:
93536
CAPACITY: 6CENSUS: 3DATE:
05/30/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:Therese Fonseca / LicenseeTIME VISIT/
INSPECTION COMPLETED:
03:45 PM
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On 05/30/2025 Licensing Program Analyst (LPA) Evelin Rios conducted an Annual Required visit and inspection of the facility. The inspection tool was used for todays visit. LPA arrived to the facility and was greeted by staff #1 (S1) who granted access. LPA met the administrator shortly after and explained the reason for the visit. LPA conducted a physical plant tour at 1:17 p.m., and LPA observed the following: At entry LPA observed appropriate postings on the wall near the front door and the hallway leading to residents' bedrooms.

Kitchen: In the kitchen LPA observed the kitchen to be clean and clear of clutter. Appliances and fixtures were functional. LPA also observed a 7 day supply of non-perishable amount of food and a 2 day supply amount of perishable food in the facility. LPA observed a second staff, staff#2 (S2) in the facility. LPA observed cleaning products locked in a cabinet under the kitchen sink.

Bedrooms: LPA observed a total of five (5) bedrooms designated for residents' use. One (01) bedroom may be shared. Resident bedrooms were observed clean and clear of clutter, properly furnished with appropriate beds, night stands and chairs. Doors in bedrooms leading to the outside had auditory alarms that were observed functional. LPA observed night-lights through out the facility.

Bathrooms: There are three (03) bathrooms designated for residents' use. Bathrooms were properly supplied and had functional fixtures. From 1:32 p.m. to 1:35 p.m. LPA took the hot water temperature from two (02) out of three (03) bathrooms and they measured between 114.6 and 118.1 degrees Fahrenheit, within regulation.
(Continue on LIC809-C)
NAME OF LICENSING PROGRAM MANAGER: Eva Miller
NAME OF LICENSING PROGRAM ANALYST: Evelin Rios
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/30/2025
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
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: RAYWOOD VILLA INC
FACILITY NUMBER: 197610381
VISIT DATE: 05/30/2025
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Common Areas: These included living room, and the dining area. The common areas were properly furnished. The dining area has a table with chairs to sit the capacity of the facility. The living room has a television with seating that was observed in good repair. LPA observed activities and games for the residents.
Outside/Surrounding Grounds: LPA observed that the entry/exits were free of obstruction. There is a shaded area for residents to use and furniture appropriate for outdoor use. The backyard has a enclosed patio that offers shade for residents. The patio area is sufficient in space for outdoor exercise and activities. There is a fish pond not in use closed and locked with wood and grate.

Laundry/Garage: The laundry room leads to the attached garage. The door to the laundry room was observed locked. Cleaning supplies and detergents are kept locked in the garage. The garage is used for facility storage.

Smoke detectors/carbon monoxide. All resident rooms are equipped with smoke detectors and the facility's smoke detectors are hard wired and interconnected. The carbon monoxide detector is located in a hallway leading to bedrooms. Detectors were tested by licensee at 1:35 p.m., and were observed operational. A fire extinguisher located by the kitchen was observed fully charged with service date 04/10/25.

From 1:37 p.m. to 2:30 p.m., LPA reviewed three (03) of three (03) resident records and (3) staff records. Records were observed locked in the medication cabinet. Two (02) out of three (03) staff records reviewed did not have health screenings completed with TB test conducted prior to providing care in the facility. LPA collected a copy of the Certificate of Liability Insurance. LPA reviewed administrator certificate, infection control plan and LIC610E. LPA reviewed residents' centrally stored medication and medication records. LPA observed medications are centrally stored and locked in a closet. LPA observed a complete first aid kit in the closet. One (01) out of the (03) residents medication records reviewed did not have a signed, dated written order for PRN medications from a physician on file.

Deficiency cited during today’s visit (refer to LIC809-D). Exit interview conducted. Licensee was unable to stay for the duration of the visit and designated Arlina Jarin to sign todays report. Copy of appeal rights and report provided to .
NAME OF LICENSING PROGRAM MANAGER: Eva Miller
NAME OF LICENSING PROGRAM ANALYST: Evelin Rios
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2025
LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 05/30/2025 03:33 PM - It Cannot Be Edited


Created By: Evelin Rios On 05/30/2025 at 02:45 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: RAYWOOD VILLA INC
FACILITY NUMBER: 197610381

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/30/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(a)(11)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) A health screening as specified in Section 87411, Personnel Requirements - General.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in two (02) out of three (03) staff records did not have health screening with TB test conducted which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/13/2025
Plan of Correction
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Licensee agreed to provided copy of Health Screening with TB test results to LPA by POC due date.
Type B
Section Cited
CCR
87465(e)
Incidental Medical and Dental Care Services
(e) For every prescription and nonprescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician on a prescription blank, maintained in the resident's file, and a label on the medication. Both the physician's order and the label shall contain at least all of the following information.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in one (01) out of three (03) resident records did not have a dated written order for PRN medications from a physician on file. which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/13/2025
Plan of Correction
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Licensee agreed to provide a copy of PRN authorizations forms with medication lists to LPA by POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Eva Miller
NAME OF LICENSING PROGRAM MANAGER:
Evelin Rios
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/30/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/30/2025


LIC809 (FAS) - (06/04)
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