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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405800923
Report Date: 01/12/2026
Date Signed: 01/12/2026 10:12:13 AM

Document Has Been Signed on 01/12/2026 10:12 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:SOUTHBAY MAXI CAREFACILITY NUMBER:
405800923
ADMINISTRATOR/
DIRECTOR:		LITA C. LAZOFACILITY TYPE:
740
ADDRESS:1410 13TH STREETTELEPHONE:
(805) 528-1725
CITY:LOS OSOSSTATE: CAZIP CODE:
93402
CAPACITY: 6CENSUS: 3DATE:
01/12/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
07:41 AM
MET WITH:TIME VISIT/
INSPECTION COMPLETED:
11:15 AM
NARRATIVE
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 At 8:00am on 01/12/2025, Licensing Program Analyst (LPA) Jeffries arrived to the facility unannounced to conduct the annual facility inspection. LPA met with Licensee/Administrator Lita Lazo announced who he is and the reason for the visit.
LPA noted that this is a 7 bedroom, 3 bathroom, single resident occupancy bedrooms and 1 staff room (room#5), there are 2 living rooms, a dining room, kitchen and laundry room. the garage is a converted storage area. There is seating and shade both in the back yard and the front yard with shade for resident activities and visitations. LPA noted that each room has proper furnishing, linins, and lighting. LPA noted that the bathrooms have liquid soap and paper towels and water temperature tested throughout the facility is within regulation permitters of 105*-120*(f). LPA observed at least 2 days of perishable foods and 7 days of non permeable foods on hand for at least 6 residents and staff. LPA discovered expired food in the freezer and noted a "rotting" smell in the dining room. Citation and civil penalty issue for repeat violation for less than 12 months (87555(b)(8)). LPA noted that the emergency water supply is located in the garage storage area. LPA noted that the medications are locked in the dining room and there is a complete first aide kit also located with the medications. LPA noted that there are smoke detectors located throughout the facility and carbon monoxide detector is located in kitchen doorway. LPA noted that the facility is clean and in good repair. LPA observed fire extinguishers primed and in the green and currently tagged as working. LPA observe all door ways and passage ways to be free and clear of obstacle. LPA noted that required postings are in the kitchen and hallways of the facility. LPA conducted a review of Emergency Disaster Plan, Infection Control Plan, Staff and Resident Files and a cursory review of Centrally Stored Medication Records (CSMR).
Administrator/Licensee and LPA conducted a full review of the annual care tools module and noted one violation and civil penalty issued for repeat violation with in 12 months.
Exit interview, report read, violation and civil penalty issued, appeal rights and report provided.
NAME OF LICENSING PROGRAM MANAGER: Kelly Burley
NAME OF LICENSING PROGRAM ANALYST: Mark Jeffries
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 01/12/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/12/2026
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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Document Has Been Signed on 01/12/2026 10:12 AM - It Cannot Be Edited


Created By: Mark Jeffries On 01/12/2026 at 10:01 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: SOUTHBAY MAXI CARE
FACILITY NUMBER: 405800923

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/12/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87555(b)(8)


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on two expired meats stored in the facaility freezer, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/26/2026
Plan of Correction
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Licsensee aggreed to go through all foods in the refrigerator and freezer and entire facility to discard all expired foods and properly lable foods kept. Licensee will send photographs to text or eamil of LPA of refrigerator of fresh foods on hand in 14 days of this citation. LPA may conduct physical inspection.
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: 01/12/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/12/2026


LIC809 (FAS) - (06/04)
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