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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850108
Report Date: 11/06/2025
Date Signed: 11/06/2025 08:18:48 PM

Document Has Been Signed on 11/06/2025 08:18 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:OAK PLACE RESIDENTIAL CAREFACILITY NUMBER:
565850108
ADMINISTRATOR/
DIRECTOR:		FLORDELIZA HIPOLITOFACILITY TYPE:
740
ADDRESS:50 OAK ST.TELEPHONE:
(805) 586-4086
CITY:CAMARILLOSTATE: CAZIP CODE:
93010
CAPACITY: 36CENSUS: 36DATE:
11/06/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:15 PM
MET WITH:Flordeliza "Baby" HipolitoTIME VISIT/
INSPECTION COMPLETED:
04:45 PM
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Licensing Program Analyst (LPA) Valeria Conway conducted a Case Management - Deficiencies visit in conjunction with complaint visit (Complaint Control # 29-AS-20251028223301). LPA met with Administrator Flordeliza "Baby" Hipolito. The purpose of the visit is to issue citations for deficiencies observed during the initial complaint investigation. Entrance interview.

According to the SOC341 form filed with Community Care Licensing (CCL) on 10/29. and information obtained through the complaint investigation, the administrator acknowledged awareness that the facility driver (S1) suffers from PTSD and may become agitated displaying rude or inappropriate behavior at times. During today’s visit, it was also disclosed that S1 is related to administrator. Based on the information obtained from the SOC341 and interviews conducted, it appears that the administrators Baby and Becky Spring were aware of S1’s behavioral issues but failed to take proactive measures to ensure that residents were treated with dignity and respect, and that their personal rights and safety were protected. Interviews conducted with clients revealed that several clients have experienced rude and impatient behavior from S1. As a precaution, LPA review the Guardian background system, which confirmed that S1 is associated with the facility and eligible to work in a licensed RCFE. However, the administrator did not meet the requirements under Title 22 regulations to ensure that all employees demonstrator appropriate behavior and do not pose a risk to the residents in care.

During today’s visit, at approximately 1 p.m., LPA conducted a phone interview with S1. During the conversation, S1 admitted that during an off-site visit with Client #1 (C1), they became very upset with the medical office staff and annoyed by C1. When confronted by the supervisor at the doctor’s office regarding their behavior, S1 reportedly cursed at the supervisor.

Continued on LIC 809-C

NAME OF LICENSING PROGRAM MANAGER: Desaree Perera
NAME OF LICENSING PROGRAM ANALYST: Valeria Conway
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 11/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/06/2025
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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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: OAK PLACE RESIDENTIAL CARE
FACILITY NUMBER: 565850108
VISIT DATE: 11/06/2025
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Continued from LIC 809

The supervisor then asked S1 to leave the premises. S1, the sole staff attending for C1, departed the location abandoning C1, leaving them unsupervised. Upon returning to the facility without C1, the administrator had to arrange for another staff member to retrieve and transport C1 to the facility safely. The administrator stated that as result of this event, the licensee suspended S1 until further notice.

The following deficiencies were cited from the California Code of Regulations, Title 22 and California Health & Safety Code. (See LIC 809-D). The Administrator was informed that failure to correct deficiencies may result in future civil penalties. Civil penalties of $500 are assessed for a zero-tolerance violation.

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: 11/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/06/2025 08:18 PM - It Cannot Be Edited


Created By: Valeria Conway On 11/06/2025 at 03:17 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: OAK PLACE RESIDENTIAL CARE
FACILITY NUMBER: 565850108

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/06/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/07/2025
Section Cited
CCR
87411(a)

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87411(a) Personnel Requirements - General. Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs.
This requirement was not met as evidenced by.
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Staff #1 was immediately removed from their position and placed on suspension pending further administrative review. The administrator agreed to submit a written statement to the Dept. outlining corrective measures to prevent recurrence of similar incidents.
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Based on a telephone call with S1 there was an absence of supervision of C1 when S1 abandoned client at the medical facility during an appoinment resulting in an immediate threat to the health and safety of residents in care.
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Also, Administrator will notify the LPA of the final employment action taken regarding Staff #1 (rehire, reassignment, or termination) before POC due date .
Type A
11/07/2025
Section Cited
CCR87405(h)(2)

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87405(h)(2) Administrator Qualifications and Duties (h) The administrator shall have the responsibility to:(2) ...report to the licensee on the operation of the facility, and provide the licensee...standards of care and supervision. This requirement was not met as evidenced by.
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Administrator agreed to submit a written statement of understanding acknowledging the regulation cited and the importance to protect resident's personal right and report incident and ensure continued compliance to LPA before POC due date.
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Based on statements the administrator did not comply with the regulation cited above by not protecting the client's personal rights resulting in an immediate threat to the health and safety of residents in care
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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: 11/06/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/06/2025


LIC809 (FAS) - (06/04)
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