197610527-3-14-2026-31-AS-JGTN-DS6VHA-20260314162649

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610527
Report Date: 03/14/2026
Date Signed: 03/14/2026 04:27:01 PM

Document Has Been Signed on 03/14/2026 04:27 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:	CLAIRE'S VILLA		FACILITY NUMBER:	197610527
ADMINISTRATOR/ DIRECTOR:	FRANCISCO, CLAIRE JITH M.		FACILITY TYPE:	740
ADDRESS:	39430 11 STREET WEST		TELEPHONE:	(818) 427-3257
CITY:	PALMDALE	STATE: CA	ZIP CODE:	93551
CAPACITY: 6		CENSUS: 4	DATE:	03/14/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	12:08 PM
MET WITH:	Claire Francisco - Administrator		TIME VISIT/ INSPECTION COMPLETED:	03:30 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Jose Tan conducted an Annual Required inspection of this facility today. LPA initially met with staff Leonita Garcia, who called the Administrator Claire Francisco. The Administrator arrived 10 minutes later and explained the reason for the visit. A tour of the physical plant was conducted at 12:18 PM and the following was noted: There is only one entrance being utilized at the facility. The facility had submitted and approved Infection Control and Mitigation plan. The facility has a designated visitors' area at the backyard. The facility has sufficient stock of PPE in the storage room. The facility has five (5) bedrooms and three (3) bathrooms currently occupying four (4) residents. One (1) bedroom is designated for staff use. The facility is fire cleared for six (6) non-ambulatory residents, one of which may be bedridden on Room #5. The facility is also has an approved hospice waiver for six (6) residents. Kitchen: The kitchen appliances and fixtures were functional. LPA found a sufficient amount of perishable and non-perishable food at the facility; properly stored. Knives were stored in a locked drawer in the kitchen. Bedrooms: All five (5) resident rooms were properly furnished with appropriate beddings and linens with sufficient lighting. Bathrooms: The bathroom for residents' use was observed to have grab bars, non-skid mats and properly supplied with hygiene products. Hot water temperature was measured at a range of 112.5°F to 112.8°F. LPA did not observe any toxins or cleaning supplies in any of the bathrooms during the day's visit. (continued on LIC 809-C)

NAME OF LICENSING PROGRAM MANAGER: Troy Agard
NAME OF LICENSING PROGRAM ANALYST: Jose Gary Tan
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 03/14/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2026

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 3

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)

Page: 2 of 3

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: CLAIRE'S VILLA	FACILITY NUMBER: 197610527
	VISIT DATE: 03/14/2026

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

(continued from LIC 809)

Common Areas: These included the living room and dining area. The common areas were properly furnished. The dining room area and table is large enough to accommodate up to six (6) residents. The auditory alarms on all exit doors were on and functional at the time of the visit. There is a fire extinguisher located in the kitchen and was last inspected on 02/18/26. Dual smoke/carbon monoxide alarms are hardwired and inter connected, tested and observed to be operational.

Surrounding Grounds: Entry/exits were free of obstruction. There was furniture appropriate for outdoor
use. The outdoor area was free of hazards. The laundry room is located going through to the garage and was locked at the time of the visit. Detergents and cleaning supplies are kept in the laundry room cabinet observed to be locked and inaccessible. There is no body of water at the facility. There is a tool shed in the backyard observed to be locked during visit.

Garage: The garage was currently being used as frozen food, toxins and other cleaning supplies storage. The garage is attached to the facility but could only be accessed through the laundry room.

Resident Files: Resident files are kept in a locked medication closet located by the bedroom hallway. LPA conducted a file review of resident records. Resident records are complete and updated.. Staff Files: Staff files are kept in a locked closet, also by the dining room. LPA conducted a file review of staff records and observed that the files are complete and updated.

Medications: Medications are kept in a locked closet by the bedroom hallway. Medications and Medication Records were reviewed for proper storage and documentation. There is a complete first aid kit located in the medication closet. Disaster drill was last conducted on 12/04/25. Required posting observed in facility (complaint hot line poster).

Pursuant to Title 22 Division 6 of the CA Code of Regulations, there were no deficiencies observed during the visit. Exit Interview Conducted and a Copy of the Report Issued.

NAME OF LICENSING PROGRAM MANAGER: Troy Agard
NAME OF LICENSING PROGRAM ANALYST: Jose Gary Tan
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 03/14/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2026

LIC809 (FAS) - (06/04)

Page: 3 of 3