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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565801019
Report Date: 01/12/2026
Date Signed: 01/12/2026 05:25:26 PM

Document Has Been Signed on 01/12/2026 05:25 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:MOUNTAIN VISTA OF OJAIFACILITY NUMBER:
565801019
ADMINISTRATOR/
DIRECTOR:		NICKIE PEREZFACILITY TYPE:
740
ADDRESS:602 EAST OAK STREETTELEPHONE:
(805) 646-6850
CITY:OJAISTATE: CAZIP CODE:
93023
CAPACITY: 38CENSUS: 27DATE:
01/12/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Nickie PerezTIME VISIT/
INSPECTION COMPLETED:
05:30 PM
NARRATIVE
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At 10:00 a.m. Licensing Program Analyst (LPA) Esther Cortez arrived at the facility unannounced to conduct a required annual visit. The LPA was greeted by Assistant Administrator Theresa Burdick and Administrator Nickie Perez and informed them of the reason for the visit.

Record Review: A review of facility files was initiated. Facility records are stored in a locked office. The LPA observed documentation of Infection Control, Disaster prevention and last disaster drill (conducted on 11/12/2025). The LPA obtained Client Roster, Staff Roster, and Insurance Liability. The LPA reviewed five (5) of twenty-seven (27) resident files. Residents’ records were reviewed for, but not limited to care plans, medical records, admissions agreement, consent forms. All resident records were in order. The LPA reviewed five (5) of twenty-two (22) staff files. Personnel records and Administrator’s file were reviewed for, but not limited to personnel records, health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All staff records were complete and current.

Medications: A medication review was conducted for three out of five residents and the following was observed. The medications were stored in a medication room and med carts which are locked and inaccessible to the residents. Medications are properly documented on the Centrally Stored Medication and Destruction Record (CSMDR).

Interviews: The LPA conducted three (3) resident and three (3) staff interviews. No concerns were voiced. Report will continue on LIC809-C, 2nd page.
NAME OF LICENSING PROGRAM MANAGER: Kasandra Lopez
NAME OF LICENSING PROGRAM ANALYST: Esther Cortez
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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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: MOUNTAIN VISTA OF OJAI
FACILITY NUMBER: 565801019
VISIT DATE: 01/12/2026
NARRATIVE
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The LPA conducted a tour of the physical plant with Administrator Nickie Perez to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The following was noted: Facility is a residence that consists of two (2) buildings, with ten (10) resident rooms in each building. Building #2 is two stories and the second story is designated solely for staff. The LPA observed fire extinguishers throughout the facility, which were fully charged and last serviced 01/09/2026. All smoke alarms and carbon monoxide detectors were tested and functioned properly. The LPA observed all required postings throughout the facility. The facility serves residents with dementia, the auditory alarms on the exit doors were tested and functioned properly at the time of visit.

Kitchen: During the facility tour, the kitchen appeared clean and the appliances and fixtures functional. The LPA observed a sufficient amount of perishable and non-perishable food at the facility. Food is prepared based on the menu. Snacks and beverages are available for residents. The LPA observed one of two kitchen refrigerators with the temperature of 49*F, upon observation the Administrator stated that the attached thermometer was not working properly and placed a second thermometer inside the fridge, however that thermometer was also showing temperature above 40*F.
Bedrooms: During today’s visit, the LPA observed five (5) randomly selected resident units. The resident bedrooms were properly furnished with at least one chair, nightstand and sufficient lighting for each resident. The bedrooms had appropriate and adequate bedding and linens such as sheets, pillowcases, mattress pads, and blankets.
Bathrooms: The LPA observed all bathrooms, properly supplied and had functional fixtures. The LPA observed grab bars and non-skid mats in all bathrooms. Water temperature measured in the restrooms in both buildings ranged between 110.7 degrees Fahrenheit and 117.5 degrees Fahrenheit.

Common Areas: These included the dining areas and living areas. The common areas were checked for cleanliness and furniture was checked for functionality during time of visit. There were no obstructions and/or tripping hazards throughout the facility. Cleaning supplies and toxins were observed locked and inaccessible. Surrounding Grounds (Outdoors)/Garage: The LPA observed appropriate outdoor furniture, with a covered shaded area for residents. The garage is detached and locked at all times. No bodies of water were observed.

Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D): Exit interview conducted and copy of the report and appeal rights provided.

NAME OF LICENSING PROGRAM MANAGER: Kasandra Lopez
NAME OF LICENSING PROGRAM ANALYST: Esther Cortez
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
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/12/2026 05:25 PM - It Cannot Be Edited


Created By: Esther Cortez On 01/12/2026 at 04:59 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: MOUNTAIN VISTA OF OJAI
FACILITY NUMBER: 565801019

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

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87555(b)(21)
General Food Service Requirements
(b) The following food service requirements shall apply: (21) Freezers of adequate size shall be maintained at a temperature of 0 degree F (-17.7 degree C), and refrigerators of adequate size shall maintain a maximum temperature of 40 degree F. (4 degree C). They shall be kept clean and food stored to enable adequate air circulation to maintain the above temperatures.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation the licensee did not comply with the section cited above in one refrigerated that was observed with the temperature of 49*F, upon observation administrator attempted to fix the temperature however temperature was still over 40*F which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/16/2026
Plan of Correction
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The Adminsitrator agrees to move all food out of the refrigerator and fix the refrigerator temperature. Will submit proof to the LPA by 1/16/26.
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.
Kasandra Lopez
NAME OF LICENSING PROGRAM MANAGER:
Esther Cortez
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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