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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610817
Report Date: 10/22/2025
Date Signed: 10/23/2025 10:34:15 AM

Document Has Been Signed on 10/23/2025 10:34 AM - 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:PALMS RESIDENTIAL LIVINGFACILITY NUMBER:
197610817
ADMINISTRATOR/
DIRECTOR:		LOPEZ, MARLENFACILITY TYPE:
740
ADDRESS:43835 HALCOM AVETELEPHONE:
(661) 547-0848
CITY:LANCASTERSTATE: CAZIP CODE:
93536
CAPACITY: 6CENSUS: 0DATE:
10/22/2025
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:25 PM
MET WITH:Marlen Lopez - ApplicantTIME VISIT/
INSPECTION COMPLETED:
03:20 PM
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Licensing Program Analyst (LPA) Evelin Rios conducted a Pre-Licensing Inspection with the applicant representative / administrator, Marlen Lopez. An application to operate a Residential Care Facility for the Elderly was received by Community Care Licensing (CCL) on 05/06/2025. The fire clearance was approved on 09/24/2025 for six (6) non-ambulatory residents for a total capacity of six with a hospice waiver granted for six.

A tour of the physical plant was initiated at approximately 12:30 p.m., and the following was observed:

BEDROOMS: There are five (5) bedrooms designated for resident use. Bedroom #1 is shared. The applicant/administrator furnished the resident bedrooms with beds, night stand, chairs, dresser, bedding and linen. The bedrooms have sufficient lighting and closet space. Passageways and exits from each bedroom is free and clear of any obstruction.

BATHROOMS: The facility has two (3) bathrooms. Bedroom #3 has it's own bathroom with shower. All bathrooms were observed to have the proper fixtures, grab bars, and non-skid mats. The hot water in two (2) bathrooms was tested and measured between 108.5 and 111.4 degrees Fahrenheit within regulation.

COMMON AREAS: These include the living room, sitting room and dining room. The living room is furnished with sufficient seating, couches, and table. There is a fireplace that is non-functional and the gas key has been removed. No fireplace tools present. The dining room table can accommodate the six (6) residents. Common areas were observed free from any hazards. Sitting area has a filing cabinet that is able to lock which will used to store resident and staff files. (Continue to LIC809-C)
NAME OF LICENSING PROGRAM MANAGER: Nichelle Gillyard
NAME OF LICENSING PROGRAM ANALYST: Evelin Rios
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 10/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/22/2025
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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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: PALMS RESIDENTIAL LIVING
FACILITY NUMBER: 197610817
VISIT DATE: 10/22/2025
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The smoke alarms and carbon monoxide detector are dual, hard wired and inter-connected. The facility has two fire extinguisher, located by the entrance and the kitchen/dining room area. The fire extinguishers were purchased on 03/26/2025.

KITCHEN: The kitchen area is equipped with a refrigerator, stove/oven, dishwasher, microwave and sink. LPA observed sufficient amount of perishable and non perishable food items. There is an adequate supply of emergency food and water. There is also sufficient dining ware to accommodate the capacity of the facility. Knives and sharps were observed locked in a kitchen drawer. Cleaning supplies will be kept locked in a cabinet underneath the kitchen sink. First aid kit and manual will be maintained in a cabinet in the kitchen.

LAUNDRY ROOM: The laundry room is able to lock. The laundry room has a washer and dryer. Detergents, and cleaning supplies will be stored locked in a cabinet next to the washer and dryer. Medications will be stored in a cabinet that is able to lock inside the laundry room.

GARAGE: There is a detached garage, used for storage.

Component III was conducted with the Licensee representative / administrator. Pre-Licensing is complete, and this facility has no deficiencies. This report will be sent to Centralized Application Bureau (CAB). You are not allowed to begin operating until you have been notified that your license has been approved by the CAB Analyst. Failure to comply could affect approval of your license.

Exit interview conducted. Copy of this report provided.
NAME OF LICENSING PROGRAM MANAGER: Nichelle Gillyard
NAME OF LICENSING PROGRAM ANALYST: Evelin Rios
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/22/2025
LIC809 (FAS) - (06/04)
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