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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610542
Report Date: 02/28/2026
Date Signed: 02/28/2026 01:42:49 PM

Document Has Been Signed on 02/28/2026 01:42 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:CASANOVA CARE HOMEFACILITY NUMBER:
197610542
ADMINISTRATOR/
DIRECTOR:		FLORES, RODERICKFACILITY TYPE:
740
ADDRESS:44315 CASA NOVA DR.TELEPHONE:
(661) 206-8026
CITY:LANCASTERSTATE: CAZIP CODE:
93536
CAPACITY: 6CENSUS: 5DATE:
02/28/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:00 AM
MET WITH:Marilyn Marbella - DesigneeTIME VISIT/
INSPECTION COMPLETED:
02:00 PM
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Licensing Program Analyst (LPA) Evelin Rios arrived to this facility to conducted an Annual Required Inspection visit. When LPA arrived she was greeted by the designee, Marilyn Marbella. Staff contacted the Administrator, Roderick Flores and informed him LPA was at the facility. LPA explained the purpose of the visit. Administrator arrived 1:30 PM and met with LPA in the facility.

In the facility LPA observed two (2) residents sitting at the dinning table eating breakfast. At approximately 8:21 AM, LPA initiated the physical plant tour of the facility inside and out. At the entrance LPA observed appropriate postings and a sign in log for visitors. At 8:23 AM LPA requested a copy of the facility's Emergency Disaster Plan (610E) for review and to update the Regional Office file. The administrator certificate posted is active.

LPA observed the fire extinguisher on a wall in the common area. The fire extinguisher was fully charged and had a service tag indicating it was last serviced on 09/05/2025. The facility has an open concept layout that includes the kitchen, living area, and dining area. In the kitchen LPA observed appliances and fixtures were functional. LPA observed cookware and residents’ tableware to be in good repair. LPA observed a sufficient amount of two-day perishable and 7 day non-perishable food in the refrigerator and pantry. Knives and sharps were stored in a locked cabinet. LPA observed a staff washing dishes and cleaning the kitchen counters. The facility telephone is accessible to residents on the kitchen counter.


(Continue to LIC809-C)
NAME OF LICENSING PROGRAM MANAGER: Mary G Flores
NAME OF LICENSING PROGRAM ANALYST: Evelin Rios
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)
Page: 1 of 7
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: CASANOVA CARE HOME
FACILITY NUMBER: 197610542
VISIT DATE: 02/28/2026
NARRATIVE
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In the living area and dining area LPA observed the furniture to be in good repair and sit the capacity of the facility. There is a television, activity books and puzzles for residents. LPA did not observe tripping hazards. Doors leading to the outside have auditory alarms there were on and functioning properly during the visit.

There are five (5) bedrooms designated for residents. Bedroom #5 can be shared. The facility has a fire clearance (STD850) dated 01/07/2026, designating Bedroom #2 for a bedridden resident and all other bedrooms for non ambulatory residents. Bedroom designated for residents use were furnished with a bed, night stand, chair, dresser, bedding, sufficient lighting and closet space. LPA observed half bed rails on Resident #1's (R1's) bed in bedroom #1. LPA observed full beds rails on Resident #2's (R2's) bed in bedroom #2. In the hallway leading to bedrooms #4 and #5, a carbon monoxide detector was observed and tested at 8:36 AM, and it was functioning properly. LPA observed smoke detectors through out the facility. LPA observed the designee test them at XX:XX PM and they were observed functioning.

The facility has two (2) bathrooms. Bedroom #5 has a private bathroom. The other bathroom is located in the hallway, outside of bedroom #4 and #5. LPA observed the bathrooms had functioning plumbing and fixtures equipped with grab bars, and non-skid mats. The hot water delivered in the common bathroom was measured at 8:40 AM and read 113.8 degrees Fahrenheit, within regulation.

The backyard has a shaded area with a table. LPA observed the passageways to the exit were clear of obstruction. The facility had removed pavers and will remodel backyard. Currently the backyard has a space with concrete flooring and dirt but still offers a sufficient amount of out door space for residents. There is no swimming pool or bodies of water.

The garage is attached to the facility and has an entrance through the laundry room. Detergents and cleaning supplies are kept locked, in the laundry room. LPA observed a second refrigerator in the garage where the overflow of food is stored. The garage is also used for storage and has emergency food and water.

(Continue to LIC809-C) Page 2 of 3
NAME OF LICENSING PROGRAM MANAGER: Mary G Flores
NAME OF LICENSING PROGRAM ANALYST: Evelin Rios
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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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: CASANOVA CARE HOME
FACILITY NUMBER: 197610542
VISIT DATE: 02/28/2026
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(Continued from LIC809-C)

Facility records for staff and residents along with medication were observed locked in hallway cabinets. From 9:25 AM to 12:00 PM, LPA conducted a file review of five (5) resident files to ensure licensing forms were complete and in compliance. Review of the medical assessment (LIC 602A) indicated that R1's ambulatory status is bedridden due to physical condition. R1 is residing in a non ambulatory bedroom. According to designee, R2 is in bedroom #2 because they are bedridden. LPA's review of medical assessment (LIC602) identifies R2 as non ambulatory although LPA observed other documentation indicating a bedridden status. LPA could not find and was not provided a half bed rail order for R1. LPA could not find and was not provided a full bed rail order for R2. LPA's review of Resident #4's (R4) file revealed R4 did not have a re appraisal completed since resident was admitted and later discharged from skilled nursing on 08/08/2025. LPA also observed a medical assessment (LIC602) for R4 from 2022 but no routine annual visit was on file for R4.

In addition, LPA also conducted a file review of three (3) staff records to insure training documents are in compliance and complete. Medication and Medication Records were reviewed for proper storage and documentation.

LPA reviewed and obtained copies of the Register of Facility Residents (LIC9020), Personnel Report (LIC500), and the facility’s liability insurance to update the Regional Office file.

Pursuant to Title 22 Division 6 of the CA Code of Regulations, there were deficiencies observed during the visit. Refer to LIC809-D. An immediate Civil Penalty was assessed. Exit Interview was conducted and a copy of the report was provided to the Administrator.

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NAME OF LICENSING PROGRAM MANAGER: Mary G Flores
NAME OF LICENSING PROGRAM ANALYST: Evelin Rios
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)
Page: 4 of 7
Document Has Been Signed on 02/28/2026 01:42 PM - It Cannot Be Edited


Created By: Evelin Rios On 02/28/2026 at 12:13 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: CASANOVA CARE HOME
FACILITY NUMBER: 197610542

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/28/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87202(a)(2)
Fire Clearance
(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal: (2) Bedridden persons

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. Resident #1 (R1) is designated as bedridden but is residing in a bedroom approved only for non ambulatory residents, which poses an immediate health, safety, and personal rights risk to persons in care.
POC Due Date: 03/01/2026
Plan of Correction
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Administrator will clarify R1’s ambulatory status with the resident’s physician, as R1 is able to turn and reposition in bed without assistance. Administrator will notify the Department if R1 and R2 will be switching rooms as R2 may be non ambulatory.
Type A
Section Cited
CCR
87608(a)(5)(A)
Postural Supports
(A) A bed rail that extends from the head half the length of the bed and used only for assistance with mobility shall be allowed.

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. One (1) out of five (5) residents, Resident #1 (R1), was observed having a half bed rails, which poses an immediate health, safety, and personal rights risk to persons in care
POC Due Date: 03/01/2026
Plan of Correction
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Administrator removed bed rails for now. Administrator will obtain a half bed rail order for R1 and provide a copy to the Department when it is obtained.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Nichelle Gillyard
NAME OF LICENSING PROGRAM MANAGER:
Evelin Rios
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 02/28/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/28/2026


LIC809 (FAS) - (06/04)
Page: 5 of 7
Document Has Been Signed on 02/28/2026 01:42 PM - It Cannot Be Edited


Created By: Evelin Rios On 02/28/2026 at 12:13 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: CASANOVA CARE HOME
FACILITY NUMBER: 197610542

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/28/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87463(a)
Reappraisals
(a) The pre-admission appraisal, as specified in Section 87457, Pre-Admission Appraisal, shall be updated, in writing as frequently as necessary or once every 12 months, whichever occurs first, to note significant changes in condition, as defined in Section 87101, Definitions, and to keep the appraisal accurate. For the purposes of this section, the updated pre-admission appraisal shall be referred to as the reappraisal.

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. One (1) out of five (5) residents, Resident #4 (R4), did not have a reappraisal completed after returning to the facility from a skilled nursing facility, which posed a potential health, safety, and personal rights risk to persons in care.
POC Due Date: 03/13/2026
Plan of Correction
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Administrator will conduct a re appraisal of R4 and provide copy to the Department by POC due date 03/13/2026.
Type B
Section Cited
CCR
87463(h)
Reappraisals
(h) The licensee shall request that all residents receive an annual routine visit with a licensed medical professional once every twelve months, either in person or by video appointment.

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. One (1) out of five (5) residents, Resident #4 (R4), did not have an annual visit on file, which poses a potential health, safety, and personal rights risk to persons in care.
POC Due Date: 03/13/2026
Plan of Correction
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Administrator will ensure R4 receives an annual routine visit with a licensed medical professionaland, have them complete a new medical assessemnt (LIC602) and provide a copy to the Department by POC due date 03/13/2026.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Nichelle Gillyard
NAME OF LICENSING PROGRAM MANAGER:
Evelin Rios
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 02/28/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/28/2026


LIC809 (FAS) - (06/04)
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