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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850346
Report Date: 05/19/2025
Date Signed: 05/19/2025 06:52:19 PM

Document Has Been Signed on 05/19/2025 06:52 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:MOM'S PLACE IFACILITY NUMBER:
565850346
ADMINISTRATOR/
DIRECTOR:		YUSUF, IBIRONKEFACILITY TYPE:
740
ADDRESS:4 MANSFIELD LANETELEPHONE:
(818) 274-1809
CITY:CAMARILLOSTATE: CAZIP CODE:
93010
CAPACITY: 6CENSUS: 4DATE:
05/19/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:15 AM
MET WITH:Laila KulunguTIME VISIT/
INSPECTION COMPLETED:
04:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Valeria Conway arrived at the facility unannounced to conduct a required annual visit at 10:15 A.M. The LPA was greeted by Caregiver Romeo Thompson. LPA informed the reason for the visit. Caregiver contacted the facility representative by phone, Laila Kulungu. At 10:55 A.M. facility representative arrived. Administrator, Yusuf Ibironke, was unavailable during today's visit and does not come to the facility often due to distance, however, authorized facility representative, to sign today's reports. Reason for the visit was stated. Entrance interview conducted.

At 11:10 A.M. LPA conducted a physical plant tour inside and outside to ensure there are no health and safety hazards and the facility is in compliance with Title 22 Regulations. Fire extinguisher was last purchased 04/16/2025. Between 11:32 A.M. and 11:39 A.M. two (2) carbon monoxide detectors and the hardwired smoke detectors were tested and functioned properly. According to facility representative, the door connecting the common area to the wing where rooms one (1) through four (4) are located is designated as a fire door. This door is in place to enhance safety and prevent the spread of fire.



Continued on LIC 809-C
NAME OF LICENSING PROGRAM MANAGER: Desaree Perera
NAME OF LICENSING PROGRAM ANALYST: Valeria Conway
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/19/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 11
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)
Page: 2 of 11
Document Has Been Signed on 05/19/2025 06:52 PM - It Cannot Be Edited


Created By: Valeria Conway On 05/19/2025 at 03:42 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: MOM'S PLACE I
FACILITY NUMBER: 565850346

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/19/2025

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 in by having the fire door open and not hardwire to the smoke detectors which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/19/2025
Plan of Correction
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Facility representative immediately closed the door and stated that it will remained closed at all times.
Type A
Section Cited
CCR
87309(d)
Storage Space and Access
(d) Residents may have access to items specified in subsection (c) for personal use unless there is documentation as specified in Section 87457, Pre-Admission Appraisal or Section 87463, Reappraisals, that indicates the resident's or other residents’ safety would be at risk if allowed access.

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 all chemicals in a closet to be secured with a deadbolt lock which does not requires a key to unlock which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/21/2025
Plan of Correction
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Handyman will come and change the deadbolt lock for a Keyed Entry deadbolt 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: 05/19/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/19/2025


LIC809 (FAS) - (06/04)
Page: 3 of 11
Document Has Been Signed on 05/19/2025 06:52 PM - It Cannot Be Edited


Created By: Valeria Conway On 05/19/2025 at 03:42 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: MOM'S PLACE I
FACILITY NUMBER: 565850346

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/19/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87355(e)(3)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 87355(c) or

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above by not having S1 associated to the faiclity which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/19/2025
Plan of Correction
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Licensee associated S1 during today's visit.
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 observation, the licensee did not comply with the section cited above by having discrepancies during today's medication audit which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/21/2025
Plan of Correction
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Facility respresentative will have training with staff regarding medication documentation and care staff notes. Training will be send to LPA before POC due date and a statement of understanding on regulation #87465(d) 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: 05/19/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/19/2025


LIC809 (FAS) - (06/04)
Page: 4 of 11
Document Has Been Signed on 05/19/2025 06:52 PM - It Cannot Be Edited


Created By: Valeria Conway On 05/19/2025 at 03:42 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: MOM'S PLACE I
FACILITY NUMBER: 565850346

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/19/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

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 a broken toilet paper holder, broken electrical outlet and low water pressure from the faucet located in the bathroom of room #3 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/03/2025
Plan of Correction
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Facility representative will have all these issues fixed and send proof to LPA before 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: 05/19/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/19/2025


LIC809 (FAS) - (06/04)
Page: 5 of 11
Document Has Been Signed on 05/19/2025 06:52 PM - It Cannot Be Edited


Created By: Valeria Conway On 05/19/2025 at 03:42 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: MOM'S PLACE I
FACILITY NUMBER: 565850346

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/19/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87467(a)(3)
Resident Participation in Decisionmaking
(a) Prior to, or within two weeks of the resident's admission, the licensee shall arrange a meeting with the resident, the resident's representative, if any, appropriate facility staff, and a representative of the resident's home health agency, if any, and any other appropriate parties, to prepare a written record of the care the resident will receive in the facility, and the resident's preferences regarding the services provided at the facility. (3) The licensee shall arrange a meeting with the resident and appropriate individuals identified in Section 87467(a)(1) to review and revise the written record as specified, when there is a significant change in the resident's condition, or once every 12 months, whichever occurs first. Significant changes shall include, but not be limited to occurrences specified in Section 87463, Reappraisals.

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 bymissing signatures for resident's responsible party on all needs and service plans which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/03/2025
Plan of Correction
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Facility representative will contact every resident's responsible party to reviewed and sign all Needs and service plans.

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: 05/19/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/19/2025


LIC809 (FAS) - (06/04)
Page: 6 of 11
Document Has Been Signed on 05/19/2025 06:52 PM - It Cannot Be Edited


Created By: Valeria Conway On 05/19/2025 at 03:42 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: MOM'S PLACE I
FACILITY NUMBER: 565850346

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/19/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87608(a)(5)(A)
Postural Supports
(A) A bed rail that extends from the head half the length of the bed and used only for assistance with mobility shall be allowed.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above by not having a prescription or a note stating that full bed rails are required for R1 receiving hospice services which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/03/2025
Plan of Correction
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Facility representative will submit a copy of the prescription to LPA before POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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2
3
4
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: 05/19/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/19/2025


LIC809 (FAS) - (06/04)
Page: 7 of 11
Document Has Been Signed on 05/19/2025 06:52 PM - It Cannot Be Edited


Created By: Valeria Conway On 05/19/2025 at 04:18 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: MOM'S PLACE I
FACILITY NUMBER: 565850346

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/19/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87412(d)
The licensee shall maintain documentation that an administrator has met the certification requirements specified in Section 87406, Administrator Certification Requirements or the recertification requirements in Section 87407, Administrator Recertification Requirements.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interviews with staff, the licensee did not comply with the above cited section, as there is not a qualified administrator running the facility due to distance, which posed a potential health and safety risk to persons in care.
POC Due Date: 05/20/2025
Plan of Correction
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3
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A statement of understanding shall be submitted to CCL before POC due date.
Section Cited
Deficient Practice Statement
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2
3
4
POC Due Date:
Plan of Correction
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2
3
4
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: 05/19/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/19/2025


LIC809 (FAS) - (06/04)
Page: 8 of 11
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: MOM'S PLACE I
FACILITY NUMBER: 565850346
VISIT DATE: 05/19/2025
NARRATIVE
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Continued from LIC 809-C

KITCHEN: The LPA observed the kitchen to be clean. Kitchen appliances appeared to be in operable condition. The facility has a sufficient supply of perishable and non-perishable food. Additional non-perishable food supplies were observed inside a cabinet adjacent to the kitchen. LPA conducted a review of expiration dates on product labels. LPA observed sharps and knives locked in a kitchen drawer. At 11:20 A.M. hot water measured at 117.2 * F.

COMMON AREAS: This includes the living room and dining room areas. LPA observed common area 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 comfortable temperature of 72 degrees. LPA observed a working phone available for residents. The LPA observed the required postings in the common area and a fireplace was observed adequately screened. During the inspection, the LPA observed a fire door held open by a magnet; however, when the smoke detectors were tested, the fire door did not release and close as expected. The administrator immediately closed the door during today’s visit and acknowledged that the door will be maintained closed at all times or the wiring connecting the fire door to the smoke alarms should function properly in the event of a fire to be in compliance with fire safety requirements. Cleaning supplies are located in a separate cabinet next to the main entrance. LPA observed the door to be secured with a deadbolt lock which does not requires a key to unlock. Per facility’s representative, a handyman is scheduled to install a keyed entry deadbolt.

BATHROOMS: There are two and a half (2 1/2) shared restrooms in the facility. All restrooms were observed to be clean and sanitary and in operating condition. Showers were also observed to have grab bars and slip resistant mats and surfaces with sufficient amounts of soap and paper products in each restroom. The LPA observed low pressure from the faucet located in the bathroom of room #3, as well a broken toilet paper dispenser in the hallway’s shared bathroom. Water temperature was measured in all shared restrooms and measured within the required range.

Continued on LIC 809-C

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

DATE: 05/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2025
LIC809 (FAS) - (06/04)
Page: 9 of 11
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: MOM'S PLACE I
FACILITY NUMBER: 565850346
VISIT DATE: 05/19/2025
NARRATIVE
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3
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5
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12
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14
15
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32
Continued from LIC809-C

BEDROOMS: The facility has five (5) bedrooms total; one bedroom is shared, and the rest are private. The den is used as a staff room and remains locked. All resident bedrooms observed were furnished and contained beds, chairs, bedside tables and lamps. All beds have appropriate linens. There is also an ample supply of linen, towels and paper products. LPA observed a broken electrical outlet in vacant room #5, also, Resident #1(R1), a hospice recipient, had full rails on their bed.

LAUNDRY ROOM: The facility's laundry room is connected to the home but only accessible from outside. Laundry supplies are kept inside the locked closet in the house.

GARAGE: The Garage remains locked and inaccessible to the residents in care. LPA observed extra PPE supplies, cleaning supplies, a refrigerator with extra food for staff and residents and mobility devices.



OUTDOOR SPACE: The backyard has a covered patio which had shade and seating areas for residents to enjoy. Facility has three (3) side gates. LPA observed all gates to be self-closing and self-latching gates with clear passageways for emergency exit use. Facility provides sufficient space to accommodate both indoor and outdoor activities. There were no bodies of water on the premises at the time of the visit.

RECORD REVIEW: Between 12:45 P.M. and 2:17 P.M., staff and resident records were reviewed. During the resident’s record review, LPA observed Resident #1 (R1) to be at risk if allowed direct access to personal grooming and hygiene items. All other records were observed to be complete. However, all residents were missing authorized representative’s signatures on their Needs and Service Plan. During the staff’s record review LPA observed, all files to be complete. LPA requested facility administrator’s file for compliance, however, facility representative was unable to produce it. According to our records, administrator’s certificated expired on 01/16/2025 and no renewal applications have been received at this time. Licensee is working to get a new administrator assigned to this facility. Additionally, a comparison of the LIC 500 (Personnel Record) and the Guardian System reflected that Staff #1 (S1) was fingerprinted but not associated to the facility. During today’s visit, Licensee associated S1.

Continued on LIC809-C

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

DATE: 05/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2025
LIC809 (FAS) - (06/04)
Page: 10 of 11
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: MOM'S PLACE I
FACILITY NUMBER: 565850346
VISIT DATE: 05/19/2025
NARRATIVE
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Continued from LIC 809-C

INFECTION CONTROL/EMERGENCY DISASTER PLANNING: During today’s visit, the LPA reviewed the facility's infection control practices and emergency disaster plan. The facility’s policies and procedures as it pertains to infection control are adequate. Emergency disaster drills are conducted quarterly, with the last drill documented on 04/06/2025.

MEDICATION REVIEW: Locked medication cabinet is in the dining room and the kitchen. Between 2:10 P.M. and 3:20 P.M. Medications for four (4) residents were observed. LPA observed prescribed medications for Resident #2 (R2) -Bumetanide 2MG Tablet (16qty)- to be taken twice a daily. The Centrally Stored Medication Log indicates a start as of 05/01/2025. However, medication count in the bubble pack did not match the expected quantity bases on the prescribed dosage and start date.

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: 05/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2025
LIC809 (FAS) - (06/04)
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