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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610457
Report Date: 02/28/2026
Date Signed: 02/28/2026 01:57:51 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 02/28/2026 01:57 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:KEEPSAKE CAREFACILITY NUMBER:
197610457
ADMINISTRATOR/
DIRECTOR:		DANIELS, TEJEIRAFACILITY TYPE:
740
ADDRESS:43528 32ND ST ETELEPHONE:
(909) 771-9565
CITY:LANCASTERSTATE: CAZIP CODE:
93535
CAPACITY: 4CENSUS: 0DATE:
02/28/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:15 AM
MET WITH:Tejeira DanielsTIME VISIT/
INSPECTION COMPLETED:
01:15 PM
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On 02/28/26026 at 10:15 am Licensing Program Analyst (LPA) Lorena Casillas met with Administrator Tejeira Daniels for an unannounced one (1) year required visit for this facility. LPA was greeted and granted access by Administrator. LPA explained the reason for the visit and an entrance interview was conducted.

The facility is fire cleared for two (2) non-ambulatory residents and two (2) ambulatory residents for a total capacity of four (4). Currently there are no residents living in the facility as they are waiting to be vendorized by North Los Angeles Regional Center.

Infection Control and Emergency Preparedness Plan: LPA reviewed facility Infection Control Plan and Emergency Preparedness Plan to make sure protocols are being reviewed and/or updated. Plans were discussed and updated.

The tool kit was not used, as there are no residents in the facility yet. A tour of the physical plant was initiated at approximately 11:00 am and the following was observed:

KITCHEN: LPA conducted a tour of the kitchen at 11:00 am and observed there to be sufficient stock of two-day perishable and seven-day non-perishable foods. Food storage and preparation areas are clean and inaccessible to pests. LPA observed all knives and sharp objects locked and inaccessible to residents in the staff office located in an area of the living room. The medications will be stored in a locked cabinet in the kitchen.
NAME OF LICENSING PROGRAM MANAGER: Nichelle Gillyard
NAME OF LICENSING PROGRAM ANALYST: Lorena Casillas
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.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: KEEPSAKE CARE
FACILITY NUMBER: 197610457
VISIT DATE: 02/28/2026
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BEDROOMS: There are three (3) bedrooms designated for resident use. Two (2) rooms are designated as private rooms. One (1) bedroom will be shared. The bedrooms have beds, nightstands, chairs, dressers, bedding and linen. All rooms had sufficient lighting.

BATHROOMS: The facility has two (2) bathrooms. All bathrooms were observed to have the proper fixtures, and non-skid mats. The hot water delivered in the bathrooms measured 118.3˚F.

COMMON AREAS: These included the living room and dining room areas, which were equipped with living room furniture, a television, tables, and chairs. The dining room table is large enough to accommodate up to four (4) residents. There is a fireplace with a glass barrier. No fireplace tools or fixtures are present. There were no visible immediate hazards. The smoke alarms are hard-wired inter-connected and are functional. The carbon monoxide detector is functional and installed by the entrance. The facility has one fire extinguisher that was fully charged on 01/06/2026. It is located in the common area near the entrance.



LAUNDRY ROOM: The laundry room is locked and located adjacent to the kitchen. Cleaning detergents and supplies are locked and inaccessible.

SURROUNDING GROUNDS: LPA toured the outside area of the facility and observed the driveway, passageways and entrance to the home to be clear of obstruction. The backyard of the facility has a patio and enough backyard furniture to accommodate four (4) residents. The facility backyard has sufficient yard space for outdoor activities and has a covered porch for shade. There are no swimming pools or bodies of water.

GARAGE: LPA observed the garage to be attached to the facility and currently being used for extra storage. There are no additional refrigerators or freezers.

ADMINISTRATIVE: Administrator Certificate, and Liability Insurance was emailed to LPA. Annual fees are current.

RESIDENT & STAFF FILES: LPA did not conduct a file review as there are no residents or staff.

No citations issued. Exit interviewed conducted and a copy of the report was provided to the Administrator.
NAME OF LICENSING PROGRAM MANAGER: Nichelle Gillyard
NAME OF LICENSING PROGRAM ANALYST: Lorena Casillas
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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