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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565801056
Report Date: 09/10/2025
Date Signed: 09/10/2025 01:47:55 PM

Document Has Been Signed on 09/10/2025 01:47 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:MILLENNIUM CARE IIFACILITY NUMBER:
565801056
ADMINISTRATOR/
DIRECTOR:		IRIS VAN KRALINGENFACILITY TYPE:
740
ADDRESS:5694 FEARING STREETTELEPHONE:
(805) 527-7798
CITY:SIMI VALLEYSTATE: CAZIP CODE:
93063
CAPACITY: 6CENSUS: 5DATE:
09/10/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:56 AM
MET WITH:Iris Van KralingenTIME VISIT/
INSPECTION COMPLETED:
02:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Martha Arroyo arrived at the facility unannounced to conduct a required annual visit. Upon arrival, there were three (3) staff and five (5) residents present. The LPA was greeted by staff and at this time the reason for the visit was explained. The Administrator, Iris Van Kralingen arrived at approximately 09:15 a.m. Entrance interview conducted.

During today’s inspection, the LPA along with the Administrator toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The following was observed:

Kitchen: The LPA inspected the kitchen/food service area at approximately 09:18 a.m. Knives and sharps were observed locked and inaccessible in a kitchen drawer. Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. Refrigerator and food pantry were checked for proper labels and expiration dates.

Common Areas: At the time of the visit, furniture in the common areas was observed to be in good condition. The facility maintained a comfortable temperature. The LPA observed several fire extinguishers throughout the facility to be recently charged with a date of 06/15/2025. Required postings were observed throughout the common space. There is a working telephone on premises. Activities were observed in the living room. Auditory alarms were observed functioning during the inspection. No hazards/obstruction observed inside or out.

Report Continued on LIC 809C...

NAME OF LICENSING PROGRAM MANAGER: Desaree Perera
NAME OF LICENSING PROGRAM ANALYST: Martha Arroyo
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/10/2025
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 09/10/2025 01:47 PM - It Cannot Be Edited


Created By: Martha Arroyo On 09/10/2025 at 01:20 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: MILLENNIUM CARE II
FACILITY NUMBER: 565801056

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/10/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(a)(4)
Incidental Medical and Dental Care Services
(4) The licensee shall assist residents with self-administered medications as needed.

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 as 2 out of 4 residents medications pill count did not match that with start dates documented on centrally stored during medication review, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/19/2025
Plan of Correction
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The Administrator has agreed to have an in-house staff training on medication administration and submit proof to CCL no later than POC due date.
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.
Desaree Perera
NAME OF LICENSING PROGRAM MANAGER:
Martha Arroyo
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/10/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/10/2025


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: MILLENNIUM CARE II
FACILITY NUMBER: 565801056
VISIT DATE: 09/10/2025
NARRATIVE
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Report Continued from LIC 809...

Restrooms: There are two (2) restrooms for resident use. The first bathroom is located by the main hallway and the second bathroom is located in bedroom #2. Bathrooms were clean and sanitary and in operating condition with grab bars and non-skid surfaces. The bathrooms were sufficiently stocked with supplies and paper towels. Starting at 09:29 a.m., the hot water temperature was measured in both bathrooms, and they measured within the required range of 105 – 120 degrees Fahrenheit. Personal hygiene items were observed locked and inaccessible to residents at the time of the inspection.

Bedrooms: There are three (3) bedrooms for resident use. All bedrooms are designated as double / shared occupancy. Resident rooms were observed to be furnished appropriately with linens, appropriate furnishings, and sufficient lighting. The LPA observed a staff bedroom on premises.

Laundry Room: The washer and dryer were observed locked and inaccessible to residents at the time of the inspection. Detergents and cleaning supplies were observed in a locked cabinet inside the laundry room.

Garage: The garage was locked and inaccessible to residents at the time of the visit. The LPA observed an adequate amount of emergency food and water. An adequate amount of Personal Protection Equipment (PPE) was also observed.

Outdoors: The backyard and front yard each has a covered patio area with patio furniture adequate for resident use. There is (1) side gate with latching mechanisms. The LPA observed a pool locked and inaccessible to residents in care at the time of the visit. All passageways were observed to be clear of any obstructions.

Report Continued on LIC 809C...

NAME OF LICENSING PROGRAM MANAGER: Desaree Perera
NAME OF LICENSING PROGRAM ANALYST: Martha Arroyo
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2025
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: MILLENNIUM CARE II
FACILITY NUMBER: 565801056
VISIT DATE: 09/10/2025
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Report Continued from LIC 809C...

RECORDS: The LPA began record review at approximately 09:42 a.m.

Five (5) resident files were reviewed for, but not limited to, the following: signed admission agreements, current medical assessments with TB results, LIC627(c) Consent for Treatment form, and current needs and services plan. All files were in order.

Three (3) personnel files were reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, first aid/CPR training, and the appropriate yearly training. All files were complete.

Emergency Disaster Planing: During today’s visit, the LPA reviewed the facility's emergency disaster plan, which was observed to be complete and recently reviewed/updated. Emergency disaster drills conducted quarterly as per regulation; the last one was conducted on 09/08/2025.

Medications: Medications review began at approximately 11:30 a.m. Medications are centrally stored and kept in a locked cabinet adjacent to the living room. All medications including PRNs were labeled, stored, and locked inaccessible to residents in care. During medication review, two out of four residents’ medication pill count did not match that according to the start dates on file.

Pursuant to Title 22, California Code of Regulations (CCR), the following deficiencies are cited (refer to LIC809-D). Failure to correct deficiencies may result in civil penalties.

Exit interview conducted. A copy of report and appeal rights were provided.

NAME OF LICENSING PROGRAM MANAGER: Desaree Perera
NAME OF LICENSING PROGRAM ANALYST: Martha Arroyo
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2025
LIC809 (FAS) - (06/04)
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