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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 421703748
Report Date: 01/08/2026
Date Signed: 01/08/2026 11:31:21 AM

Document Has Been Signed on 01/08/2026 11:31 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:PURISIMA HILLSFACILITY NUMBER:
421703748
ADMINISTRATOR/
DIRECTOR:		SUSAN MARSHFACILITY TYPE:
740
ADDRESS:237 ALDEBARAN AVENUETELEPHONE:
(805) 733-4395
CITY:LOMPOCSTATE: CAZIP CODE:
93436
CAPACITY: 6CENSUS: 3DATE:
01/08/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:30 AM
MET WITH:Administrator, Susan MarshTIME VISIT/
INSPECTION COMPLETED:
02:51 PM
NARRATIVE
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 At 8:30am on 01/08/2026. Licensing Program Analyst (LPA) Jeffries arrived to the facility unannounced to conduct the facility annual inspection. LPA also issued final findings on a separate complaint report on this visit. LPA met with Administrator Susan Marsh who provided verbal permission for Care Staff Elena Perez (S1) to sign for both complaint and annual inspection as Administrator had appointments.
LPA toured facility with facility staff. The facility has 4 single occupancy and 1 double occupancy bedrooms and 3 bathrooms. LPA noted backyard and front yard both had chairs, tables and shade for resident activities and visitations. LPA noted two smoke detectors functioning and working properly where located at each end of the hallway. Fire extinguisher is located in the kitchen and is fully charged and serviced. Inside and outside passageways are free from obstruction. There are no bodies of water on the facility property. The facility temperature was 73 degrees F. Water temperatures were noted to be within 105-120* (f). Residents’ rooms are appropriately furnished with adequate lighting. LPA observed more than two days of perishable and more than seven days of non-perishable food. An Emergency and Disaster Plan and Personal Rights are available and located on the facility kitchen wall. LPA observed Administrator Certificate to be current. Resident and Staff files reviewed. LPA's reviewed Emergency Disaster Plan and Infection Control Plan. LPA reviewed Centrally Stored Medications Records. LPA noted that at this time there were no issues with record reviews. LPA noted that the carbon monoxide detector was not functioning at the time of annual inspection due to dead batteries and a citation was issued.. LPA noted that Administrator ordered a plug-in carbon monoxide detector for replacement during annual inspection. LPA conducted a full review of annual care tools with S1 and Administrator.

Exit interview, report read, citation 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: 01/08/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/08/2026
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 01/08/2026 11:31 AM - It Cannot Be Edited


Created By: Mark Jeffries On 01/08/2026 at 11:12 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: PURISIMA HILLS
FACILITY NUMBER: 421703748

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/08/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1569.311


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and physical test, the licensee did not comply with the section cited above in one count of Carbon Monoxcide Detector not fuctioning properly, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/09/2026
Plan of Correction
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During annual inspection on 01/08/2026, Administrator order, online (WallMart) a plug in Carbon Monoxcide detector that is scheduled to be delevered by due date of plan of correction, Administrator will follow up with a picture of new CO2 detector, plugin. to LPA's cell phone and or email.
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: 01/08/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/08/2026


LIC809 (FAS) - (06/04)
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