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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565801482
Report Date: 04/09/2026
Date Signed: 04/10/2026 09:25:41 AM

Document Has Been Signed on 04/10/2026 09:25 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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:VIA ESMERALDA L.L.C.FACILITY NUMBER:
565801482
ADMINISTRATOR/
DIRECTOR:		ESMERALDA OCAMPO-NUNEZFACILITY TYPE:
740
ADDRESS:3521 EAST ELMA ST.TELEPHONE:
(805) 216-6195
CITY:CAMARILLOSTATE: CAZIP CODE:
93010
CAPACITY: 6CENSUS: 4DATE:
04/09/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:20 AM
MET WITH:Esmeralda Ocampo-NunezTIME VISIT/
INSPECTION COMPLETED:
04:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Valeria Conway arrived at the facility unannounced to conduct a required annual visit at 10:20 A.M. LPA met with licensee/administrator Esmeralda Ocampo-Nunez and explained the reason for the visit. Administrator On-call Janette Villapando arrived shortly after.

At 10:40 A.M. LPA and licensee toured the physical plant areas inside and outside to ensure there are no health and safety hazards and that facility is in compliance with Title 22 Regulations. Fire extinguishers are fully charged and last serviced 03/21/2026. Between 11:13 A.M. and 11:17 A.M. smoke detectors and carbon monoxide detectors units in each room, living room and kitchen were tested and functioned properly. The facility converted the garage into an ADU (accessory dwelling unit). ADU has a separate address (3521 1/2 East Elma St.). The adults living in the facility and the ADU are all fingerprint cleared and associated to this facility.

BEDROOMS: There are three double-occupied resident bedrooms which were furnished appropriately with clean linen, appropriate furnishings and sufficient lighting. The facility has two other rooms used as bedrooms by staff.

BATHROOMS: There are three (3) bathrooms at the facility. One in the main suite which would be used by residents sharing that room. One in the hallway used by the other residents and staff. One in a staff suite which is used only by staff/ADU occupants. Bathrooms are clean and sanitary and in operating condition with grab bars and slip-resistant mats and surfaces. Between 10:54 A.M. and 11:25 A.M. hot water temperature measured between 105-120 degrees Fahrenheit which was within the required range.

Continued on LIC 809

NAME OF LICENSING PROGRAM MANAGER: Desaree Perera
NAME OF LICENSING PROGRAM ANALYST: Valeria Conway
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/09/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/09/2026
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 04/10/2026 09:25 AM - It Cannot Be Edited


Created By: Valeria Conway On 04/09/2026 at 03:13 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: VIA ESMERALDA L.L.C.
FACILITY NUMBER: 565801482

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/09/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(d)
Incidental Medical and Dental Care Services
(d) If the resident is unable to determine his/her own need for a prescription or nonprescription PRN medication, and is unable to communicate his/her symptoms clearly, facility staff designated by the licensee, shall be permitted to assist the resident with self-administration, provided all of the following requirements are met:

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 by not maintaining current prescribed medication in stock or discontined orders which poses an immediate health risk to persons in care.
POC Due Date: 04/10/2026
Plan of Correction
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Administrator will write a statement of understanding prior to the POC due date. Additionally, they will obtain a current medications or documentation of discontinued medications and submit them to the LPA prior to 4/24/2026.
Type A
Section Cited
CCR
87465(e)
Incidental Medical and Dental Care Services
(e) For every prescription and nonprescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician on a prescription blank, maintained in the resident's file, and a label on the medication. Both the physician's order and the label shall contain at least all of the following information.

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 as four out of four residents did not have a current active medication list nor orders for all active medications which poses an immediate health risk to persons in care.
POC Due Date: 04/10/2026
Plan of Correction
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Administrator will write a statement of understanding prior to the POC due date. Additionally they will request current list of medication and copy of all orders and submit to LPA before
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:
Valeria Conway
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/09/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/09/2026


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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: VIA ESMERALDA L.L.C.
FACILITY NUMBER: 565801482
VISIT DATE: 04/09/2026
NARRATIVE
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Continued from LIC 809-C

KITCHEN: The kitchen appeared clean. There was a sufficient supply of perishable and non-perishable food. LPA conducted a review of expiration dates on product labels. Appliances appear to function properly. Knives are stored locked in an outdoor storage shed. At 11:35 A.M. hot water measured at 114.6 degrees Fahrenheit.

COMMON AREAS: LPA observed common areas, including living room, dining area, and patio to be clean and properly furnished at the time of the visit. The facility serves residents with dementia, the auditory alarms on the exit doors were tested and functioned properly at the time of visit. The facility maintained a temperature of 71 degrees. LPA observed cameras throughout the common areas only. LPA observed a working phone available for residents use whenever needed.

OUTDOOR SPACE: The backyard has a covered patio area with patio furniture. Facility has two total gates; both were observed to be self-closing gates with clear passageway for emergency exit use. During the inspection the LPA observed 7 locked sheds located in the backyard, in them there were PPE supplies, pans, pots and kitchen supplies, sharps, yard tools, emergency food, party and decoration supplies, mechanical aids and devices such as crutches, walkers, and wheelchairs, folding chairs and tables, exercise equipment and extra storage room. Facility provides sufficient space to accommodate both indoor and outdoor activities. LPA observed outside cameras around the perimeter of the house and a small water fountain.

Laundry room: Inside a locked room adjacent to the living area, LPA observed the washer and dryer. The laundry room leads to the ADU where cleaning supplies and disinfectants are kept stored in a locked cabinet inside.

Continued on LIC 809-C
NAME OF LICENSING PROGRAM MANAGER: Desaree Perera
NAME OF LICENSING PROGRAM ANALYST: Valeria Conway
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/09/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/09/2026
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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: VIA ESMERALDA L.L.C.
FACILITY NUMBER: 565801482
VISIT DATE: 04/09/2026
NARRATIVE
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Continued from LIC 809-C

RECORD REVIEW: Between 11:50 A.M. and 1:00 P.M., staff and resident records were reviewed. Facility staff and residents’ files are stored in a locked file cabinet. Four (4) resident and three (3) personnel records were reviewed for documents including, but not limited to: health screening, TB test, staff training records, fingerprint clearance, resident physician's report, needs and service appraisal, and personal rights, health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All records were observed to be complete.

MEDICATION REVIEW: Between 1:12 P.M. and 2:40 P.M. Medications for four (4) residents were observed. During the record reviewed the LPA observed that four (4) out of four (4) residents did not have a current medication list on file. Additionally, physician orders were not maintained in the resident’s file as required. While the LPA was auditing the medication, the Administrator contacted Resident #1’s (R1’s) physician’s office and requested a current medication list. Upon receipt, it was noted that two (2) medications (Ferrous Sulfate and Furosemide) listed by the physician were not documented on the Centrally Stored Medication and Destruction Record, nor were corresponding prescriptions available. According to the Administrator, these medications had been discontinued; however, documentation of the discontinuation order from the physician was not available for review.

Additionally, the LPA reviewed the facility's infection control practices and the facility's emergency disaster plan. Emergency disaster drills are conducted quarterly, with the last drill conducted on 03/06/2026.

Pursuant to Title 22, California Code of Regulations and/or CA Health and Safety Code, the following deficiencies were cited (refer to LIC 809-D.) Administrator was informed that failure to correct the deficiencies may result in civil penalties.

Exit interview conducted, appeal rights discussed, and a copy of this report and appeal rights were provided.

NAME OF LICENSING PROGRAM MANAGER: Desaree Perera
NAME OF LICENSING PROGRAM ANALYST: Valeria Conway
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/09/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/09/2026
LIC809 (FAS) - (06/04)
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