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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850348
Report Date: 05/06/2025
Date Signed: 05/06/2025 04:22:58 PM

Document Has Been Signed on 05/06/2025 04:22 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 2FACILITY NUMBER:
565850348
ADMINISTRATOR/
DIRECTOR:		YUSUF, IBIRONKEFACILITY TYPE:
740
ADDRESS:30 LA PATERA CTTELEPHONE:
(818) 274-1809
CITY:CAMARILLOSTATE: CAZIP CODE:
93010
CAPACITY: 6CENSUS: 4DATE:
05/06/2025
TYPE OF VISIT:POCUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:56 AM
MET WITH:Laila KulunguTIME VISIT/
INSPECTION COMPLETED:
02:00 PM
NARRATIVE
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At 10:56 A.M. LPA Conway conducted an unannounced Plan of Correction (POC) visit to follow up regarding the plan of corrections that were due for submission. The LPA was greeted by Nonso Enemchukwu. LPA informed the reason for the visit. Caregiver contacted the facility representative by phone, Laila Kulungu. At 11:56 A.M. facility representative arrived. At 11:57 A.M. Licensee, Joseph Jose, was contacted by phone and informed of LPA’s visit. Neither administrator nor Licensee were available during today's visit. due to distance, but authorized facility representative, to sign today's reports. Reason for the visit was stated. Entrance interview conducted.

During required annual visit on 04/16/25, LPA cited CCR 87219(h)(1) with a due date of 04/30/2025 and CCR 87412(d) with a due date of 05/01/2025. As of today, these two (2) plans of corrections for deficiencies cited have not been cleared.

On 04/24/25, LPA Conway, requested information from the Administrator Certification Bureau (ACB) Department regarding the status of the administrator on record. In response, the ACB indicated that administrator on record, Yusuf Ibironke, has administrator certificates for RCFE: 7033113740. Expiration date: 1/16/2025 and ARF: 7033113735. Expiration date: 4/5/2023. According to ACB records, no renewal applications have been received at this time.

Continued on LIC 809-C

NAME OF LICENSING PROGRAM MANAGER: Desaree Perera
NAME OF LICENSING PROGRAM ANALYST: Valeria Conway
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/06/2025
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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Document Has Been Signed on 05/06/2025 04:22 PM - It Cannot Be Edited


Created By: Valeria Conway On 05/06/2025 at 11:24 AM
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 2
FACILITY NUMBER: 565850348

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/06/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/06/2025
Section Cited
CCR
87202(a)

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87202(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... fire protection services, or the State Fire Marshal: This requirement is not met as evidenced by:
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Facility staff immediately closed the door during today's visit. Facility representative that the door would remain closed at all times in compliance with fire safety requirements.
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Based on LPA observation, the licensee did not comply with the section cited above by having the fire door improperly held open by an industrial doorstop which poses/posed a potential health, safety or personal rights risk to persons 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: 05/06/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/06/2025


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: MOM'S PLACE 2
FACILITY NUMBER: 565850348
VISIT DATE: 05/06/2025
NARRATIVE
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Continued from LIC 809

In regard to the facility’s patio area, which was found to be inadequately furnished during the required annual visit, the LPA requested that the licensee provide proof of purchase and a photo of the installed patio furniture by 04/30/25. On 05/01/25, the LPA emailed facility representative to follow up, as the due date had passed without submission. On 05/02/25, the facility representative texted proof of purchase, indicating a scheduled delivery time of 11 A.M. on the same day. The LPA requested a photo of the installed patio furniture be submitted by the end of the day on 05/05/2025. During today’s visit LPA observed unopened boxes containing patio furniture on the facility premises. While conducting this visit facility staff assembled patio furniture. POC met.

A civil penalty of $100 per 5 days was assess for not correcting deficiency under CCR 87412(d), and a civil penalty of $100 per 6 days was assess for not correcting deficiency under CCR 87219(h)(1) before the POC due date (Refer to LIC 809D from original annual visit on 4/16/2025).

During today’s visit, at 12:00 P.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. The following deficiency was observed.

The fire door was once again improperly held open using a doorstop. During the annual visit on 04/16/25, facility representative acknowledged that the door would remain closed at all times in compliance with fire safety requirements.

An immediate civil penalty of $1,000 repeat violation is assessed today due to being cited for the same violation within 12 months. Administrator was informed that additional civil penalties might be assessed based on Health and Safety Code 1569.49(e) and 1569.49(f).

Pursuant to Title 22, California Code of Regulations, the following deficiencies are cited (refer to LIC809-D). Exit interview conducted, deficiencies cited, civil penalties assessed, appeal rights discussed, and a copy of this report issued to the facility representative.

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

DATE: 05/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

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