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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610956
Report Date: 05/04/2026
Date Signed: 05/04/2026 12:36:38 PM

Document Has Been Signed on 05/04/2026 12:36 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:PLACE LIKE HOME ASSISTED LIVING LLCFACILITY NUMBER:
197610956
ADMINISTRATOR/
DIRECTOR:		BELMONTE,MARKFACILITY TYPE:
740
ADDRESS:44515 17TH ST WESTTELEPHONE:
(661) 802-4223
CITY:LANCASTERSTATE: CAZIP CODE:
93534
CAPACITY: 6CENSUS: 0DATE:
05/04/2026
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:40 AM
MET WITH:MARK BELMONTE- AdministratorTIME VISIT/
INSPECTION COMPLETED:
01:00 PM
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On 5/04/2026 at approximately 09:40 AM, Licensing Program Analyst (LPA) Angelica Segovia conducted an announced Pre-licensing visit. LPA was greeted by the Administrator, Mark Belmonte.

An application was submitted to Community Care Licensing Division (CCLD) on 11/03/2025, Initial license for a Residential Care Facility for the Elderly (RCFE), 60 years old and older. The requested capacity is for five (5) non-ambulatory residents and one (1) bedridden resident. A total of six (6) capacity. The fire clearance was approved on 03/11/2026.

A physical plant tour was conducted, and the following was noted:

Structure: The facility is a single-story building with five (5) bedrooms and three (3) bathrooms. One (1) staff office.

Entrance: There is one (1) main entrance/exit being utilized. Required postings such as: See/Say Something and Personal Rights were observed throughout the common areas.

Common Areas: These include both living room and dining room. All common areas were observed to be neat, clean and organized. All common areas were properly furnished and in good repair. The facility maintains a comfortable temperature of sixty-eight (68) degrees. No firearms observed or will be maintained on the premises. A covered fireplace was observed. A working telephone was observed.

Residents/staff files: Resident and staff files will be kept in locked staff office, inaccessible to residents.

LIC809C-continued

NAME OF LICENSING PROGRAM MANAGER: Troy Agard
NAME OF LICENSING PROGRAM ANALYST: Angelica Segovia
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/04/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/04/2026
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: PLACE LIKE HOME ASSISTED LIVING LLC
FACILITY NUMBER: 197610956
VISIT DATE: 05/04/2026
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Kitchen: Sufficient supplies of seven (7) day nonperishable food and two (2) day perishable foods will be purchased prior to residents’ arrival. LPA observed sufficient supplies of dishes, cups and silverware readily available for the residents upon arrival. Working stove and refrigerator observed and in proper condition. The Sharps/Knives will be stored in locked kitchen drawer. The cleaning solutions/toxins were observed to be kept locked underneath the kitchen sink.

Medications: The medications will be stored in a locked storage cabinet located in the kitchen. Medication storage is equipped with a lock to ensure medications will not be accessible to residents. First-aid kit observed to be equipped with but not limited to bandages, scissors, digital thermometer, tweezer and First-Aid Manuel.

Emergency: The Fire extinguisher was observed to be located near the kitchen. LPA observed the fire extinguisher to be fully charged, and purchase receipt dated 01/13/2026.

Bedrooms: All residents’ bedrooms were observed to be properly furnished with bed, nightstand, applicable lightening and seating.

Bathroom: The bathrooms will be maintained in proper condition.

Hallways: Hallway is properly lit. Extra linens/covers were observed to be stored in storage cabinets located in the hallway’s passageway.

Laundry Room: The laundry room was observed to be located in the hallway’s passageway leading towards the bedrooms. LPA observed the laundry room to be kept locked. All cleaning solutions and toxins will be appropriately stored within the locked laundry room. Dryer and washer observed to be in proper condition.

The Garage: The garage can be accessed from inside of the facility. The garage was observed to be located near the laundry room. LPA observed the garage to be used for storage purposes.

Staff Office: The staff office will be kept locked and inaccessible to residents.

Water Temperature: The water temperature will be kept within regulations of 105°F to 120°F.

LIC809C-continued

NAME OF LICENSING PROGRAM MANAGER: Troy Agard
NAME OF LICENSING PROGRAM ANALYST: Angelica Segovia
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/04/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2026
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: PLACE LIKE HOME ASSISTED LIVING LLC
FACILITY NUMBER: 197610956
VISIT DATE: 05/04/2026
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Smoke detectors: Dual interconnected smoke detectors and carbon monoxide observed to be working properly and were tested.

Outside: The outside is clean, free of hazards, and properly furnished with sufficient seating. A shaded area for residents was observed. LPA observed a lock shed to be located in the backyard.



Pool: There is no body of water located at the facility.

Administration: The facility has submitted an Emergency and Disaster Plan for Residential Care Facilitates for the Elderly.

The Component III Orientation for Residential Care Facility for the Elderly (RCFE) was shown/reviewed with the Administrator.

Facility is in compliance with Title 22 Regulations at this time. This report will be forwarded to the Centralized Application Bureau (CAB). You will be notified by the CAB Analyst when your license has been approved.

Exit interview conducted and copy of this report issued to the administrator.

NAME OF LICENSING PROGRAM MANAGER: Troy Agard
NAME OF LICENSING PROGRAM ANALYST: Angelica Segovia
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/04/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2026
LIC809 (FAS) - (06/04)
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