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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405801701
Report Date: 10/17/2025
Date Signed: 10/17/2025 03:47:48 PM

Document Has Been Signed on 10/17/2025 03:47 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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:C.A.L.L.-CARMELITA HOUSEFACILITY NUMBER:
405801701
ADMINISTRATOR/
DIRECTOR:		JONI CHAPMANFACILITY TYPE:
740
ADDRESS:2660 FERROCARRILTELEPHONE:
(805) 466-8502
CITY:ATASCADEROSTATE: CAZIP CODE:
93422
CAPACITY: 6CENSUS: 6DATE:
10/17/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:15 AM
MET WITH:Brenda Victoria AdministratorTIME VISIT/
INSPECTION COMPLETED:
03:55 PM
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Licensing Program Analyst (LPA) De Leon arrived at facility for an unannounced annual inspection visit. LPA met with Administrator Brenda Victoria and explained the purpose of the visit.

LPA toured the inside and outside of the facility with Administrator the following was noted:
Infection Control: The facility has an infection control plan on file. The facility is clean, safe and sanitary. The facility trains staff initially upon hiring and annually thereafter on infection control and PPE. The facility has about a 30-day supply of PPE on hand. The facility has a book to sign in an out for visitors at the facility and hand sanitizer is present.
Operational Requirements: The facility is in compliance with the granted fire clearance. The facility is licensed for a capacity of 6, 5 of which can be non-ambulatory residents. The facility has an approved hospice waiver for 5.
Physical Plant & Environmental Safety: The facility is a 5 bedroom and 2 bathroom home currently occupying 6 residents. The facility has smoke detectors and 1 carbon monoxide monitor. The lighting and lamps in resident rooms are sufficient for the use of the facility and for resident’s comfort. The facility kitchen is clean, safe, and sanitary. The showers have non-skid mats. Toilet, hand washing and bathing facilities are operational. The pathways are clear of any obstructions. Facility is well lit inside and outside for safety. Disinfectant, cleaning solutions and poisons are locked in laundry room and under the kitchen sink. The facility has sufficient space inside and outside for activities and visiting. The facility has a backyard for client use with plenty of shade. The facility has telephone and internet service for resident use. The facility has fencing around the back yard with a self closing and self latching gate.
Continued 809-C
NAME OF LICENSING PROGRAM MANAGER: Kelly Burley
NAME OF LICENSING PROGRAM ANALYST: Rachael De Leon
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 10/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/17/2025
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 10/17/2025 03:47 PM - It Cannot Be Edited


Created By: Rachael De Leon On 10/17/2025 at 02:34 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: C.A.L.L.-CARMELITA HOUSE
FACILITY NUMBER: 405801701

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/17/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.696(a)
Other Provisions
(a) All residential care facilities for the elderly shall provide training to direct care staff on postural supports, restricted conditions or health services, and hospice care as a component of the training requirements specified in Section 1569.625. The training shall include all of the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 5/5 staff did not meet annual trianing for hours or topics which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/24/2025
Plan of Correction
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Administrator agreed to provide annual trianing on the required subjects and hours. Provide proof of training and an up to date LIC 500.
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:
Rachael De Leon
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/17/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/17/2025


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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: C.A.L.L.-CARMELITA HOUSE
FACILITY NUMBER: 405801701
VISIT DATE: 10/17/2025
NARRATIVE
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Staffing: The facility has 11 staff and 1 administrator. Five staff files were reviewed for Health screening with TB results, Applications, fingerprint clearances, and First Aid and CPR certificates, all forms were legible and up to date.
Personnel Records and Staff Training: The facility keeps staff files confidentially in the locked staff office. The facility administrator certificate expires on 03/20/2026. Five staff files were reviewed for initial and annual training requirements some staff are not meeting the hours or the subject matter requirements.
Residents Rights/Information: Required postings were posted in the common area of the facility, Personal Rights, Persons with disabilities, CCL Complaint poster, License, rights to resident/family councils, Non-Discrimination notice, and visiting policy hours. Internet is provided to each client and each client is given confidentiality and privacy.
Planned Activities: Four of the residents attend Day programs. The facility offers games, puzzles, arts and crafts, discussions, magazines, outings and walking.
Food Service: The facility provides 3 meals and snack daily to all residents. The facility uses a posted menu for meals. The facility has two refrigerators and one separate freezer. The temperatures are kept within regulations requirements. Residents have likes and dislikes and meals are created around that. The facility has 2 days of perishables and 7 days of non-perishables. The facility has an emergency supply of food and water.
Incidental Medical and Dental: The facility provide transportation to mecdial and dental appointments for all residents in care. The facility centrally stores medication in a locked cabinet in the medication room. All 6 residents medication was reviewed, no labels were altered, no medications were expired, and medications are being stored in their original containers.
Resident Records/Incident reports: The facility has confidential binders for residents records stored in a locked staff office. The facility sends incident reports to the department when required. Five resident files were reviewed for signed Admission Agreements, ID/Emergency information, Consent forms, Medical Assessments, Appraisal Needs and services plans are done on the IPP's, and Safeguard for Property and Valuables. The facility does have the safeguard for cash resources and P&I monies were checked with ledgers, receipts and cash.
Disaster Preparedness: The facility has the current disaster forms posted. The forms are legible and complete. The facility conducts quarterly disaster drills changing the type of disasters on each training.
The facility has the supplies listed in the disaster plan with food and water.
Continued 809-C
NAME OF LICENSING PROGRAM MANAGER: Kelly Burley
NAME OF LICENSING PROGRAM ANALYST: Rachael De Leon
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2025
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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: C.A.L.L.-CARMELITA HOUSE
FACILITY NUMBER: 405801701
VISIT DATE: 10/17/2025
NARRATIVE
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Residents with special health conditions: The facility does accept dementia residents in care. Sharps, knives, cleaning products are kept locked and made inaccessible to residents in care. The facility does not currently have any residents on hospice, home health services, or using oxygen. If they do have residents on services those plans with be kept up to date. The facility is not using any exiting doors alarms. The facility has video surveillance in the common areas.


Exit interview conducted, deficiency cited, copy of report and appeal rights printed for Administrator.
NAME OF LICENSING PROGRAM MANAGER: Kelly Burley
NAME OF LICENSING PROGRAM ANALYST: Rachael De Leon
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2025
LIC809 (FAS) - (06/04)
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