405802304-3-17-2026-29-AS-GHTO-DS9QMQ-20260317121756

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 405802304
Report Date: 03/17/2026
Date Signed: 03/17/2026 12:18:19 PM

Document Has Been Signed on 03/17/2026 12:18 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:	A HEAVENLY COMMUNITIES A		FACILITY NUMBER:	405802304
ADMINISTRATOR/ DIRECTOR:	MARTHA RAMIREZ		FACILITY TYPE:	740
ADDRESS:	2025 UNION ROAD		TELEPHONE:	(805) 296-3239
CITY:	PASO ROBLES	STATE: CA	ZIP CODE:	93446
CAPACITY: 6		CENSUS: 6	DATE:	03/17/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:05 AM
MET WITH:	Administrator - Martha Ramirez		TIME VISIT/ INSPECTION COMPLETED:	12:30 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	At 9:05am on March 17, 2026, Licensing Program Analyst (LPA) Haner-Tomasko arrived unannounced to the facility to conducted the annual facility inspection. LPA met with Administrator Martha Ramirez, announced who he was and the reason for the visit. LPA noted that the facility is one of four facilities, a recreation building, and administrative offices on approximately 2 acres that is gated. The property also has an expansive open courtyard with shaded areas for residents and visitors. During todays inspection, LPA conducted the annual inspection of only the facility listed above. Administrator and LPA conducted a full facility tour. This facility is a one-story residential home with six private resident bedrooms each with an en suite bathroom and walk-in shower. There is a great room consisting of a living room with self-contained fireplace, dining area, and kitchen. There is a designated salon room with full bathroom for the residents of this facility and the other three facilities on the property. There is a public use half bathroom at the facility entry. The medications are stored in a locked medication cart in the facility hallway. There are dual smoke/carbon monoxide detectors throughout the facility that are hardwired with backup battery. Apex Fire and Safety conducted an annual inspection of the fire sprinkler system on December 29, 2025. LPA noted that the facility is clean and in good repair with no obstructions in hallways, doorways or exits. LPA observed fire extinguishers that were tagged current and in the green compression range, serviced on December 29, 2025. (Continued on LIC809-C)

NAME OF LICENSING PROGRAM MANAGER: Kelly Burley
NAME OF LICENSING PROGRAM ANALYST: Garrett Haner-Tomasko
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 03/17/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/17/2026

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 N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: A HEAVENLY COMMUNITIES A	FACILITY NUMBER: 405802304
	VISIT DATE: 03/17/2026

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LPA conducted a sample medication audit and reviewed the facilities Centrally Stored Medication Records (CSMR) and found no violations. LPA noted fresh fruit and snacks in the kitchen for residents to enjoy freely. LPA noted that all resident meals are prepared and cooked in this facility in a separate kitchen located through a door next to the salon and delivered to the other three facilties by hand. LPA observed at least two days of perishable foods and seven days of non-perishable on hand for this facility. LPA conducted a staff and resident file review.

LPA and Administrator conducted a review of the annual care tool modules.

Exit interview conducted, report signed, and report provided to the Administrator.

NAME OF LICENSING PROGRAM MANAGER: Kelly Burley
NAME OF LICENSING PROGRAM ANALYST: Garrett Haner-Tomasko
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 03/17/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/17/2026

LIC809 (FAS) - (06/04)

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