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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565802453
Report Date: 01/23/2026
Date Signed: 01/25/2026 11:23:33 AM

Document Has Been Signed on 01/25/2026 11:23 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:AT HOME CAMARILLOFACILITY NUMBER:
565802453
ADMINISTRATOR/
DIRECTOR:		COLON, MARGARITAFACILITY TYPE:
740
ADDRESS:417 GARDENIA AVETELEPHONE:
(805) 383-8893
CITY:CAMARILLOSTATE: CAZIP CODE:
93010
CAPACITY: 6CENSUS: 2DATE:
01/23/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Celso EspirituTIME VISIT/
INSPECTION COMPLETED:
03:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Valeria Conway arrived at the facility unannounced to conduct a required annual visit at 09:30 A.M. The LPA was greeted by caregivers Felicidad Portugal and Celso Espiritu. LPA informed the reason for the visit. At 9:40 A.M., Caregiver Portugal contacted the Administrator by phone, Margarita Colon. Administrator was unavailable during today's visit, but authorized Celso Espiritu to sign today's report. Entrance interview conducted.

Beginning at 10:15 A.M., the LPA, along with caregiver Celso Espiritu 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. The following was observed:

A fire extinguisher is fully charged and purchased on 12/25/2025. Between 10:40 A.M. and 10:57 A.M. smoke detectors and two (2) Carbon Monoxide detectors were tested and functional at the time of the visit.

KITCHEN: The LPA observed the kitchen to be clean. Kitchen appliances appeared to be in operable condition. The facility has a sufficient supply of seven (7) days non-perishable and two (2) days perishable food. Cleaning supplies and sharps are located in a locked cabinet under the kitchen sink. LPA conducted a review of expiration dates on product labels. At 10:53 A.M. hot water temperature was tested and measured at 112.5 degrees Fahrenheit.

Continued on LIC 809-C

NAME OF LICENSING PROGRAM MANAGER: Desaree Perera
NAME OF LICENSING PROGRAM ANALYST: Valeria Conway
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 01/23/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/23/2026
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 01/25/2026 11:23 AM - It Cannot Be Edited


Created By: Valeria Conway On 01/23/2026 at 01:40 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: AT HOME CAMARILLO
FACILITY NUMBER: 565802453

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/23/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
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 medication audit, the licensee did not comply with the section cited above by having inaccurate pill count for both residents in care which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/26/2026
Plan of Correction
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It was agreed for the administrator to arrange a third party training on medication management for all staff members, including the administrator. Training shall address topics discussed, and a statement identifying the regulation violated (regulation 87465). Submit documentation of completion, sign in sheet identifying all attendees (Name, title, signatures)
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:
Valeria Conway
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 01/23/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/23/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/25/2026 11:23 AM - It Cannot Be Edited


Created By: Valeria Conway On 01/23/2026 at 01:40 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: AT HOME CAMARILLO
FACILITY NUMBER: 565802453

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/23/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(a)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain 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 required documents were missing from staff and administrator files which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/06/2026
Plan of Correction
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Administrator will gather all documents and submit proof to LPA via email before 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:
Valeria Conway
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 01/23/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/23/2026


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: AT HOME CAMARILLO
FACILITY NUMBER: 565802453
VISIT DATE: 01/23/2026
NARRATIVE
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Continued from LIC 809

COMMON AREAS: This includes the living room, family room, and dining room areas. LPA observed common area to be clean and properly furnished at the time of the visit. An adequately screened fireplace was noted in the living room. 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 a working phone available for residents use whenever needed. Facility provides sufficient space to accommodate indoor activities.

BATHROOMS: There are two (2) bathrooms which are designated for shared use. Restrooms were observed to be equipped with slip-resistant surfaces and contain slip-resistant mats. Grab bars were observed in the bathrooms. LPA observed all bathrooms were clean, properly supplied and had functional fixtures. Residents have sufficient amounts of supplies for personal hygiene. Hot water temperature was measured in both shared bathrooms and measured within the required range of 105-120 degrees Fahrenheit.

BEDROOMS: There are five (5) total bedrooms in the facility; 1 (one) is designated as a shared room and 4 (four) are designated as private resident rooms. Occupied rooms were observed to be furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. There is an additional bedroom for staff use.

GARAGE: Garage was observed locked and inaccessible to the residents in care. Garage contained laundry area, extra food, PPE and incontinence supplies, 1st aid kit and emergency food and water. LPA observed a low supply of emergency water. Technical assistance (TA) issued.

OUTDOOR SPACE: The backyard has a covered patio area with patio furniture for residents’ use. All passageways were observed to be clear. There were no bodies of water on the premises at the time of the visit. Facility has a side gate which was observed to be self-closing and self-latching with clear passageways for emergency exit use. LPA observed cameras throughout the outside of the property only. Facility provides sufficient space to accommodate outdoor activities. LPA observed two (2) sheds containing holiday decorations, extra PPE and incontinence supplies, mobility devices and gardening tools. The property has two (2) homes with different house numbers/address. The homes are separated by a fence.

Continued on LIC 809-C

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

DATE: 01/23/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2026
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: AT HOME CAMARILLO
FACILITY NUMBER: 565802453
VISIT DATE: 01/23/2026
NARRATIVE
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Continued on LIC 809-C

RECORD REVIEW: Starting at 11:15 A.M. Staff and resident 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. All 2 (two) resident files observed were missing the Personal Rights form (LIC 613). Technical Violation (TV) issued. All other forms were inside their files. During this visit, LPA requested two (2) staff files and the administrator’s file for review. The administrator’s file was reportedly maintained offsite and was not available at the time of the visit. Review of the two (2) caregiver files revealed missing documentation that had been available during the previous year’s visit. Missing documents included updated CPR and as personnel record or job application for Staff #1 and personnel record or job application and health screening for Staff #2.

MEDICATION REVIEW: At 12:45 P.M. medications for 2 (two) residents were observed by the LPA. Medications are maintained locked in a hallway cabinet leading to the garage and they are inaccessible to residents. All medications observed were labeled and stored properly. However, discrepancies were identified on both residents during the medication count. The following was observed: Resident’s 1 Metroprolol Succ ER 100 MG, 1 tab twice a day, with a start date of November, 9, 2025 containing 180 pills, had 25 left. Eliquis 2.5 mg, 1 tab twice a day, with a start date of January 4, 2025 containing 60 pills, had 37 pills left. Resident’s 2 Atrovastatin 40 MG take, 1 tab a day, with start date of December 15, 2025 containing 100 pills had 59 pills left.

LPA requested the following documents during today’s visit; Personnel Report (LIC 500), Resident Roster, Liability Insurance. Emergency disaster drills are conducted quarterly, with the last drill conducted on 12/28/2025. Additionally, LPA observed emergency disaster plan to be complete and updated annually, as required.

INTERVIEWS: During today's visit, LPA interviewed 2 (two) staff members and 2 (two) residents.

Pursuant to Title 22 CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D) and civil penalty issued.

Exit interview conducted. Today's reports and appeal rights were discussed, and copy will be email to the Licensee.

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

DATE: 01/23/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2026
LIC809 (FAS) - (06/04)
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