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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405801512
Report Date: 09/24/2025
Date Signed: 09/24/2025 04:27:24 PM

Document Has Been Signed on 09/24/2025 04:27 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 N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:WELCOME HOME RESIDENTIAL CARE FOR THE ELDERLYFACILITY NUMBER:
405801512
ADMINISTRATOR/
DIRECTOR:		EVELYN I. FLORENTINOFACILITY TYPE:
740
ADDRESS:402 WOODBRIDGE ST.TELEPHONE:
(805) 784-0540
CITY:SAN LUIS OBISPOSTATE: CAZIP CODE:
93401
CAPACITY: 6CENSUS: 4DATE:
09/24/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:05 PM
MET WITH:Licensee/Administrator - Evelyn FlorentinoTIME VISIT/
INSPECTION COMPLETED:
04:45 PM
NARRATIVE
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At 12:05pm, on 9/24/2025, Licensing Program Analyst (LPA) Haner-Tomasko arrived at the facility unannounced to conduct the annual facility inspection. LPA met with Licensee/Administrator Evelyn Florentino, announced who he was and the reason for the visit.

Licensee/Administrator and LPA conducted a full tour of the facility. This facility is a single story residential home with four resident bedrooms (two are dual occupancy), two full bathrooms (one is on-suite and one is for public/shared use). There is a living room, dining room, and a kitchen. The dining room has a piano for residents and visitors to enjoy. LPA noted a fireplace in the dining room, the Administrator states is not used. Access to the laundry room is through locked bi-fold doors for resident safety. The garage is through a locked door also for resident safety. LPA noted that the backyard and the front yard both have seating and shade for residents and visitors. LPA noted fresh fruit and snacks in the kitchen for residents to enjoy. The facility has wired smoke detectors in each room that are all working, the Great Western Alarm technician was actively testing the smoke detectors and alarm system during the LPA visit. The carbon monoxide detector is in the entry under the visitor log and functioning normally. LPA observed a fire extinguisher near the kitchen that was tagged current and in the green compression range, serviced on 1/14/2025. LPA tested facility hot water at 110*(f), within regulation temperatures 105*-120* (f). LPA observed at least 2-days of perishable and at least 7-days of nonperishable foods. LPA noted that the facility is clean with no obstructions in hallways, doorways or exits. Medications are locked in a medication cart.

(Continued on LIC809-C)
NAME OF LICENSING PROGRAM MANAGER: Kelly Burley
NAME OF LICENSING PROGRAM ANALYST: Garrett Haner-Tomasko
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/24/2025
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 8
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 N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: WELCOME HOME RESIDENTIAL CARE FOR THE ELDERLY
FACILITY NUMBER: 405801512
VISIT DATE: 09/24/2025
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Staff and client files are locked near the living room. LPA conducted a sample medication audit and reviewed the facilities Centrally Stored Medication Records, finding 3 of 4 resident's medications managed by the facility not logged on the centrally stored medication record as required by Title 22 regulation. LPA conducted a staff and resident file review. LPA and Licensee/Administrator conducted a review of the annual care tool modules.

Exit interview conducted, deficiency cited on LIC809-D page, report signed, appeal rights and report provided to Licensee/Administrator.

NAME OF LICENSING PROGRAM MANAGER: Kelly Burley
NAME OF LICENSING PROGRAM ANALYST: Garrett Haner-Tomasko
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2025
LIC809 (FAS) - (06/04)
Page: 3 of 8
Document Has Been Signed on 09/24/2025 04:27 PM - It Cannot Be Edited


Created By: Garrett Haner-Tomasko On 09/24/2025 at 03:05 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. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: WELCOME HOME RESIDENTIAL CARE FOR THE ELDERLY
FACILITY NUMBER: 405801512

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/24/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(a)(6)
ncidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (6) The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least one year and includes...

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 when 3 out of 4 resident's medications were not centrally stored which poses a potential health, safety and personal rights risk to persons in care.
POC Due Date: 10/08/2025
Plan of Correction
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Staff started logging medications into the Centrally Stored Medication Record during LPA visit. Licensee states they will conduct training with staff on this regulation and create a medication logging and auditing policy. Licensee will email LPA the training documentation and staff signed roster and medication log and audit policy on or before 10/08/2025.
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:
Garrett Haner-Tomasko
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/24/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/24/2025


LIC809 (FAS) - (06/04)
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