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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565802411
Report Date: 05/14/2026
Date Signed: 05/14/2026 10:57:17 AM

Document Has Been Signed on 05/14/2026 10:57 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:ANITA'S CARE VILLAFACILITY NUMBER:
565802411
ADMINISTRATOR/
DIRECTOR:		SHAFFER, JENNIFERFACILITY TYPE:
740
ADDRESS:521 LOUIS DRIVETELEPHONE:
(805) 716-3633
CITY:NEWBURY PARKSTATE: CAZIP CODE:
91320
CAPACITY: 6CENSUS: 0DATE:
05/14/2026
TYPE OF VISIT:OfficeUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:10 AM
MET WITH:Jennifer Shaffer - Licensee RepresentativeTIME VISIT/
INSPECTION COMPLETED:
11:00 AM
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On 05/14/2026, an Informal Conference was held at the Woodland Hills Adult and Senior Care Regional Office. In attendance included Licensing Program Manager (LPM) Desaree Perera, Licensing Program Analyst (LPA) Martha Arroyo, and Licensee Representative (LR) Jennifer Shaffer.

The purpose of today’s Informal Conference is to discuss a complaint dated 01/04/2022 (Complaint Control # 29-AS-20220104110534) and complaint dated 05/23/2022 (Complaint Control # 29-AS-20220523095227). The Administrative Action process was explained to the Administrator, as well as the role of an Informal Conference.

On 01/04/2022, the Department received a complaint alleging that resident developed pressure injuries while in care. The complaint was substantiated on 06/24/2022 and citation was issued for Basic Services. Additionally, the Department conducted a Case Management and issued citation for violations observed during the course of the investigation which included Prohibited Health Conditions. On 05/23/2022, the Department received a complaint alleging that facility failed to provide resident’s records to resident’s authorized representative. The complaint was substantiated on 05/31/2022 and citation was issued for Additional Personal Rights of Residents in Privately Operated Facilities.

Discussions were held regarding the admission of residents with Prohibited Health Conditions, as well as the proper protocols and Title 22 regulations related to admitting residents with Stage 3 and Stage 4 pressure injuries.

Report Continued on LIC 809C...

NAME OF LICENSING PROGRAM MANAGER: Desaree Perera
NAME OF LICENSING PROGRAM ANALYST: Martha Arroyo
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/14/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/14/2026
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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: ANITA'S CARE VILLA
FACILITY NUMBER: 565802411
VISIT DATE: 05/14/2026
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Report Continued from LIC 809...

The LR acknowledged that the resident should not have been admitted and stated that no additional residents with similar conditions have been admitted since the incident, as it served as a learning experience in properly assessing residents prior to admission to the facility. The LR stated that the resident refused assistance related to the pressure injury after being admitted to the facility, which caused the injury to worsen, although staff attempted to provide assistance at all times. LPM informed the LR that they are able to seek advice from their LPA.

Additionally, the LPM discussed the importance of properly documenting all resident care activities, including repositioning residents who require such assistance, and ensuring that all documentation is complete and accurate, including updating appraisals and service plans whenever there is a change in a resident’s condition. The LR stated that they are being more cautious and are conducting thorough assessments of residents by meeting with both the resident and their family to ensure that the facility can meet the resident’s needs prior to admission. Additionally, the LR stated that they have become more organized and are utilizing all available resources. During today’s meeting, the LR submitted a Statement of Understanding acknowledging that they have learned from this experience to ensure it does not happen again.

Exit interview conducted and a copy of report was issued.

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

DATE: 05/14/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/14/2026
LIC809 (FAS) - (06/04)
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