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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405800269
Report Date: 10/02/2025
Date Signed: 10/15/2025 08:29:59 AM

Document Has Been Signed on 10/15/2025 08:29 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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:M & L SOUTH BAY MAXI CAREFACILITY NUMBER:
405800269
ADMINISTRATOR/
DIRECTOR:		LITA C. LAZOFACILITY TYPE:
740
ADDRESS:1820 MOUNTAIN VIEW DRIVETELEPHONE:
(805) 528-7862
CITY:LOS OSOSSTATE: CAZIP CODE:
93402
CAPACITY: 6CENSUS: 0DATE:
10/02/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:04 AM
MET WITH:Licensee, Lita LazoTIME VISIT/
INSPECTION COMPLETED:
02:25 PM
NARRATIVE
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 At 9:00am on 10/02/2025. Licensing Program Analyst (LPA) Jeffries arrived unannounced to the facility to conduct the annual facility inspection. LPA met with Licensee/Administrator, Lita Lazo announced who he is and the reason for the visit.

During the time of the inspection there were zero Residents residing at this facility. Administrator and LPA conducted a cursory physical tour of the facility. LPA noted that this is an 8 bedroom, 10 bathroom, 3 living rooms (one living rooms is a dinning/living rooms), one main kitchen and one kitchenette. The outside is an expansive area around the facility and there are chars and covered patio for activities and visitors near the front entrance. Six bedrooms are single client occupancy, and the other two bedrooms are designated as staff bedrooms. All 8 bedrooms have on suite bathrooms and there are an additional two bathrooms located in common areas of the facility. All bathrooms had paper towels and liquid soap. Water temperature was tested throughout the facility to be within regulation parameters (105*-120*(f)). LPA observed proper linens and furniture in all resident bedrooms. LPA reviewed infection control plan. emergency disaster plan, and staff files. LPA reviewed all of the care tool modules with Licensee. During the physical inspection the following deficiencies were cited: (87555(b)(23)) Food storage, peanuts and fruits were left out and not properly stored which resulted in mold and knats accumulation over the peanuts and fruits; (87203) Fire Safety, two of eleven smoke detectors were not functioning at time of annual inspection; and (87307(d)(6)) Hallway leading to exit was obstructed by boxes of planed storage. At this time there are no other violations or citations issued as a result of the facility annual inspection.

Exit interview, report read, report and appeal rights provided.
NAME OF LICENSING PROGRAM MANAGER: Kelly Burley
NAME OF LICENSING PROGRAM ANALYST: Mark Jeffries
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 10/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/02/2025
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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Document Has Been Signed on 10/15/2025 08:29 AM - It Cannot Be Edited


Created By: Mark Jeffries On 10/02/2025 at 11:14 AM
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. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: M & L SOUTH BAY MAXI CARE
FACILITY NUMBER: 405800269

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/02/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87203


This requirement is not met as evidenced by: Two or 11 smoke detectors were not working during annual inspection.
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in 2 out of 11 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/16/2025
Plan of Correction
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Licensee will ensure that the all smoke detectors are functional and working. Licensee will email LPA with statement fo varification after all smoke detectors are verified as operational.
Type B
Section Cited
CCR
87307(d)(6)


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in the hallway leading to the exits near all resident rooms were partiall blocked by storage items, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/16/2025
Plan of Correction
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Licnesee agrees to remove all items in hallway leading to exit and report back to LPA by email with photograph of cleared hallway by 10/16/2025
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Kelly Burley
NAME OF LICENSING PROGRAM MANAGER:
Mark Jeffries
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/02/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/02/2025


LIC809 (FAS) - (06/04)
Page: 3 of 7
Document Has Been Signed on 10/15/2025 08:29 AM - It Cannot Be Edited


Created By: Mark Jeffries On 10/02/2025 at 11:47 AM
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. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: M & L SOUTH BAY MAXI CARE
FACILITY NUMBER: 405800269

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/02/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87555(b)(23)
General Food Service Requirements
(b) The following food service requirements shall apply: (23) All readily perishable foods or beverages capable of supporting rapid and progressive growth of micro-organisms which can cause food infections or food intoxications shall be stored in covered containers at appropriate temperatures.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
Plan of Correction
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Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Kelly Burley
NAME OF LICENSING PROGRAM MANAGER:
Mark Jeffries
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/02/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/02/2025


LIC809 (FAS) - (06/04)
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