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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850332
Report Date: 06/27/2025
Date Signed: 06/30/2025 08:10:33 AM

Document Has Been Signed on 06/30/2025 08:10 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:INFINITY CARE HOMEFACILITY NUMBER:
565850332
ADMINISTRATOR/
DIRECTOR:		MANACAP, JOCELYNFACILITY TYPE:
740
ADDRESS:944 BELMONT AVENUETELEPHONE:
(805) 419-6012
CITY:CAMARILLOSTATE: CAZIP CODE:
93010
CAPACITY: 6CENSUS: 4DATE:
06/27/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:10 AM
MET WITH:Jocelyn NanacapTIME VISIT/
INSPECTION COMPLETED:
04:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Valeria Conway conducted an unannounced annual visit to this facility at 9:10 A.M., LPA met with caregivers Blaire Murphy and Sheryl De Guzman. Administrator was contacted via telephone. At 9:40 A.M. back up administrator Harold De Guzman arrived at the facility. Administrator Jocelyn Manacap arrived at 10:00 A.M. Entrance interview conducted.

Beginning at 10:12 A.M., the LPA, along with 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. This facility doesn’t have a staff room, facility will provide 24/7 care. The following was observed:



BEDROOMS: The LPA observed the resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. There are three (3) total bedrooms, all of which are designated for shared resident use, at the time of the visit only Room #1 is being shared. During the physical plant tour, LPA observed a camera in room #1. Administrator stated that camera is not functioning, and it was uninstalled during today’s visit. Technical Violation (TV) issued.

Continued on LIC 809-C

NAME OF LICENSING PROGRAM MANAGER: Desaree Perera
NAME OF LICENSING PROGRAM ANALYST: Valeria Conway
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 06/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/27/2025
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 06/30/2025 08:10 AM - It Cannot Be Edited


Created By: Valeria Conway On 06/27/2025 at 03:23 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: INFINITY CARE HOME
FACILITY NUMBER: 565850332

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/27/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87202(a)
Fire Clearance
(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above by having both fire doors obstructed which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/27/2025
Plan of Correction
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During today's visit, administrator removed the door stop and acknowledge that doors will remain closed during business hours.
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: 06/27/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/27/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/30/2025 08:10 AM - It Cannot Be Edited


Created By: Valeria Conway On 06/27/2025 at 03:23 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: INFINITY CARE HOME
FACILITY NUMBER: 565850332

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/27/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87463(a)
Reappraisals
(a) The pre-admission appraisal, as specified in Section 87457, Pre-Admission Appraisal, shall be updated, in writing as frequently as necessary or once every 12 months, whichever occurs first, to note significant changes in condition, as defined in Section 87101, Definitions, and to keep the appraisal accurate. For the purposes of this section, the updated pre-admission appraisal shall be referred to as the reappraisal.

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 having current appraisals and incomplete admission forms which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/11/2025
Plan of Correction
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Administrator will complete all forms and submit to LPA before POC due date.
Type B
Section Cited
CCR
87212(b)(1)
Emergency Disaster Plan
(b) The plan shall be subject to review by the Department and shall include: (1) Designation of administrative authority and staff assignments.

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 having a current and updated infection control plan and emergency and disaster plan which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/11/2025
Plan of Correction
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Administrato will update all necessary information and submit complete plans to LPA before POC due date.
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: 06/27/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/27/2025


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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: INFINITY CARE HOME
FACILITY NUMBER: 565850332
VISIT DATE: 06/27/2025
NARRATIVE
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Continued from LIC 809

RESTROOMS: The LPA observed two (2) restrooms in the facility; one (1) is a shared restroom, and one (1) is a private restroom. Resident restrooms are clean and sanitary and in operating condition with grab bars and slip-resistant surfaces. Between 10:38 A.M. and 10:56 A.M., hot water was measured. All bathrooms were within the required limit of 105-120 degrees Fahrenheit.

COMMON SPACES: In the common areas, walls and flooring were checked for cleanliness and good condition. At the time of the visit, living room was observed to be in good condition. The LPA observed the required postings in the common area. Hardwired combination smoke and carbon monoxide detectors were tested by staff at 9:50 A.M. and were functional at the time of the visit. Fire extinguishers were observed to be fully charged and last serviced on 06/27/2025. Facility is equipped with two fire doors to enhance safety and prevent the spread of fire. During today’s visit, LPA observed a door stop installed on the fire door in the common area leading to the resident bedrooms and in Room #1 keeping both fire doors obstructed. The facility serves residents with dementia, the auditory alarms on the exit doors were disconnected during today’s visit. Technical Violation (TV) issued. The facility maintained a comfortable temperature of 73 degrees. LPA observed a working phone available for residents use whenever needed. LPA also reviewed the facility's emergency disaster plan and the infection control plan, which needed to be updated with staff names responsible for assignments during an emergency and practices and procedures. Emergency disaster drills are being conducted quarterly.



KITCHEN: Kitchen appliances appeared to be in operable condition. The facility has a sufficient supply of perishable and non-perishable food. LPA conducted a review of expiration dates on product labels. All knives and cleaning supplies were observed to be locked and properly stored at the time of the visit. Cleaning compounds were stored under the kitchen sink and separately from food supplies. At 11:04 A.M., hot water measured at 123.2 degrees Fahrenheit. Water heater temperature was adjusted during the visit.

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

DATE: 06/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/27/2025
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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: INFINITY CARE HOME
FACILITY NUMBER: 565850332
VISIT DATE: 06/27/2025
NARRATIVE
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Continued on LIC-809C

OUTDOOR SPACE: The side yard has a covered outdoor area equipped with furniture for resident to enjoy. There were no bodies of water noted. Facility provides sufficient space to accommodate both indoor and outdoor activities. Facility has two total gates; both were observed to be self-closing and self-latching gate with clear passageways for emergency exit use.

RECORD REVIEW: Began at 11:45 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. LPA review four (4) resident records for regulatory compliance. During the review, LPA observed that the records for Resident # 1 (R1) and Resident #2 (R2) contained incomplete information and were missing required signatures. Furthermore, LPA did not observe a current appraisal form on file for any of the four (4) residents reviewed. LPA explained administrator the importance of updating in writing as frequently as necessary significant changes in resident’s condition. LPA reviewed five (5) staff files including the administrator. All files reviewed were complete and in compliance with regulations.

GARAGE: The garage was observed locked. LPA observed extra non-perishable food, and a refrigerator with extra food. Furthermore, laundry area, as well as emergency food supply and water, and storage space was observed in the garage. All cleaning compounds were stored in areas separately from food supplies. LPA reminded administrator that given that there are no staff rooms, the facility is required to have 24/7 care, and that staff cannot use the garage or a common areas to sleep.

MEDICATION REVIEW: All medications are kept in a hallway closet. This closet is locked at all time and medication are inaccessible to residents. LPA observed a complete 1st aid kit including its manual inside that closet. Audit began at 12:46 P.M. Medications for all residents were observed to be in compliance with Title 22. Physician's Reports indicate Resident #3 (R3) is able to store and administer their own medications.

Continued on LIC 809-C

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

DATE: 06/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/27/2025
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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: INFINITY CARE HOME
FACILITY NUMBER: 565850332
VISIT DATE: 06/27/2025
NARRATIVE
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Continued from LIC 809-C

During today’s visit, LPA offered administrator, Jocelyn Manacap, the opportunity to be referred to the Technical Support Program (TSP). LPA provided the following contact information for TSP services. TSP email address TechnicalSupportProgram@dss.ca.gov and their phone number (916) 654-1549. Additionally, LPA advised the ED to review the Provider Information Notices (PINs) on CCLD's website (www.ccld.ca.gov) for further guidance and updates. ED agreed to contact TSP for further information and assistance.

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: 06/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/27/2025
LIC809 (FAS) - (06/04)
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