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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850355
Report Date: 11/21/2025
Date Signed: 11/21/2025 07:16:24 PM

Document Has Been Signed on 11/21/2025 07:16 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:HERITAGE HOME CARE LLCFACILITY NUMBER:
565850355
ADMINISTRATOR/
DIRECTOR:		PACHECO, ONYX ONASINFACILITY TYPE:
740
ADDRESS:390 FULTON STREETTELEPHONE:
(805) 824-2500
CITY:CAMARILLOSTATE: CAZIP CODE:
93010
CAPACITY: 6CENSUS: 3DATE:
11/21/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Onyx PachecoTIME VISIT/
INSPECTION COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Valeria Conway arrived at the facility unannounced to conduct a required annual visit. The LPA was greeted by an individual named "Jess". Caregiver, Arlina Caranay, contacted the Administrator by phone, Onyx Pacheco. The administrator informed LPA that they would arrive at the facility in a few hours and stated they would contact back up administrator, MayAnn Reyes to assist until their arrival. The back up administrator arrived at the facility at 9:25 A.M. and the Administrator arrived at 2:00 P.M. Reason for the visit was explained Entrance interview conducted.

LPA along with back up Administrator conducted a physical plant areas inside and outside to ensure there are no health and safety hazards, and facility is in compliance with Title 22 Regulations. The facility serves residents with dementia, the auditory alarms on the exit doors were tested and functioned properly at the time of visit. This facility doesn’t have a staff room; facility provides 24/7 care. The following was observed:

Fire extinguishers are fully charged and purchased on 05/05/2025. Hardwired combination smoke detectors and carbon monoxide detectors were tested at 10:08 A.M., and all were functional at the time of the visit. Facility is equipped with two (2) fire doors. At the time of the visit, both fire doors were in operable condition. No fire clearance concerns were observed.

Bedrooms: The facility consists of four (4) bedrooms in total, of which two (2) are private rooms and two (2) are designated for shared resident use. Bedrooms #2 and #3 are designated for single use and bedrooms #1 and #4 are designated for double occupancy. The LPA observed the resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting.

Continued on LIC 809-C

NAME OF LICENSING PROGRAM MANAGER: Desaree Perera
NAME OF LICENSING PROGRAM ANALYST: Valeria Conway
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 11/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/21/2025
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: HERITAGE HOME CARE LLC
FACILITY NUMBER: 565850355
VISIT DATE: 11/21/2025
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Continued from LIC 809

Bathrooms: The LPA observed two (2) bathrooms in the facility; one (1) is a shared bathroom for residents’ use only, and one (1) is a staff/visitor bathroom. Resident bathroom was clean and sanitary and in operating condition with grab bars and slip-resistant surfaces. Water temperature was measured in the shared resident restroom at 10:05 A.M. and measured at 111.4 degrees Fahrenheit.

Kitchen: Kitchen appliances appeared to be in operable condition. The facility had a sufficient supply of perishable and non-perishable food supply. All knives and cleaning supplies were observed to be locked and properly stored at the time. All cleaning compounds were stored in areas separately from food supplies. At 10:14 A.M. hot water temperature measured 106 degrees Fahrenheit. Furthermore, laundry area was observed between the kitchen and the visitor/staff bathroom. There, the LPA observed the washer and dryer and locked cabinets. Inside those locked cabinets facility keeps cleaning supplies, disinfectant wipes, dry emergency food and staff and personnel files. LPA observed a low supply of emergency water.

Common Spaces: The common areas were checked for cleanliness. At the time of the visit, living room and dining room furniture was observed to be in good condition. Facility maintained a temperature of 74 degrees Fahrenheit. The LPA observed the required postings in the common area. A fireplace was observed to be adequately screened. LPA observed a Ring doorbell at the main entrance. Next to the living room table there is an office space. Medication and a complete first aid kit is kept locked in the office area.

Outdoor Space: The front yard is free of obstructions. Both side gates on each side of the facility were self-latching. LPA also observed a patio in the back yard which had shade and seating areas for residents to enjoy. There were no bodies of water noted. Additionally, LPA inspected the detached garage.

Garage/Staff Break Room/Storage Room: LPA inspected the detached garage. The garage consists of two (2) back-to-back rooms. The first room stored extra incontinence supplies, extra ambulation devices and a fridge. The second room contained extra ambulatory supplies, furniture and a set of mattresses. Also, there was a closet where emergency supplies were stored. LPA explained to the administrator and backup administrator that no one should be sleeping in this area without a valid fire clearance. Furthermore, LPA discussed whether any modifications made to the facility should be submitted to the department and require permits prior to any modifications are completed.

Continued on LIC 809-C

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

DATE: 11/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2025
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: HERITAGE HOME CARE LLC
FACILITY NUMBER: 565850355
VISIT DATE: 11/21/2025
NARRATIVE
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Continued on LIC 809-C

Record Review: Began at 12:25 P.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. Three (3) resident records were reviewed. LPA observed that Resident #1 (R1) file contained only partially completed forms. The back up administrator explained that R1 was admitted two days ago and that they are in the process of obtaining the remaining documents. The LPA advised that certain documents are required prior to accepting a resident in order to properly assess the individual’s suitability for placement and ensure appropriate care. Five (5) staff records were observed. LPA requested information regarding the individual who opened the door and greeted the LPA upon arrival, and who subsequently exited the facility shortly thereafter through the back of the house rather than the main entrance. The backup administrator reported that the individual was visiting Resident #2 (R2), identifying them as R2’s friend and former neighbor, and stated that the individual does not work as a caregiver at the facility. However, during the brief period the individual was present, the LPA did not observe any interaction between the individual and R2. Additionally, the LPA informed the backup administrator that, while waiting for their arrival, the LPA observed this individual redirecting R1 to sit down to prevent a potential fall, sitting next to R1 to ensure they did not stand up unattended, and assisting them around the facility. LPA requested the individual’s full name and identification card, if available. The back up administrator provided the name of the individual. A review of the Guardian System, using the information provided by the back up administrator, confirmed that the individual is not associated and does not have background clearance or exemption.

Medication Review: Began at 2:45 P.M. Medications for three (3) residents were observed. Medications are labeled and checked for expiration dates. Medications are properly documented on the centrally stored medications and destruction record. No errors observed during the medication review.

Continued from LIC 809-C

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

DATE: 11/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2025
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: HERITAGE HOME CARE LLC
FACILITY NUMBER: 565850355
VISIT DATE: 11/21/2025
NARRATIVE
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Continued from LIC 809-C

LPA requested an updated LIC500, Resident Roster, Liability Insurance documents and last emergency drill conducted.

Emergency Drills: During last year’s annual inspection, the LPA discussed with the administrator the importance of conducting quarterly emergency drills. At 11:46 A.M., during a phone conversation, the LPA again emphasized that staff and residents must be trained to evacuate, shelter in place or follow any other procedures applicable during an emergency. The administrator was reminded that emergency drills are required by regulation to be conducted quarterly.

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. An immediate civil penalty of $100 was issued and the licensee was informed that an additional civil penalty might be assessed based on Health and Safety Code § 1569.49 (f).

Exit interview conducted, Citations/civil penalties issued /A copy of the report and appeal rights were issued.

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

DATE: 11/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2025
LIC809 (FAS) - (06/04)
Page: 5 of 8
Document Has Been Signed on 11/21/2025 07:16 PM - It Cannot Be Edited


Created By: Valeria Conway On 11/21/2025 at 03:19 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: HERITAGE HOME CARE LLC
FACILITY NUMBER: 565850355

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/21/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87355(e)
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:

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 an individual helping residents without a background clearance and association to the facility which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/21/2025
Plan of Correction
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Individual left the facility during today's inspection.
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: 11/21/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/21/2025


LIC809 (FAS) - (06/04)
Page: 6 of 8
Document Has Been Signed on 11/21/2025 07:16 PM - It Cannot Be Edited


Created By: Valeria Conway On 11/21/2025 at 03:19 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: HERITAGE HOME CARE LLC
FACILITY NUMBER: 565850355

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/21/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87457(c)
Pre-Admission Appraisal
(c) Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of their individual service needs in comparison with the admission criteria specified in Section 87455, Acceptance and Retention Limitations.

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 having partially documentation for a resident that was recently addmitted which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/05/2025
Plan of Correction
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Administrator and back up administrator agreed to complete all required pre-admission and admission documents for R1. They will ensure that all forms are fully completed, signed and maintained in R1's files to ensure ongoing compliance before POC due date.
Type B
Section Cited
HSC
1569.695(a)(2)
Other Provisions
(a)In addition to any other requirement of this chapter, a residential care facility for the elderly shall have an emergency and disaster plan that shall include, but not be limited to, all of the following: (2) Plans for the facility to be self-reliant for a period of not less than 72 hours immediately following any emergency or disaster, including, but not limited to, a short-term or long-term power failure. If the facility plans to shelter in place and one or more utilities, including water, sewer, gas, or electricity, is not available, the facility shall have a plan and supplies available to provide alternative resources during an outage.

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 low supply of emergency water which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/05/2025
Plan of Correction
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Administrator and back up administrator agreed to purchase additional emergency water to ensure an adequate supply is readily available in the event of an emergency. Also, submit photographic prood of the updated emergency water supply 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: 11/21/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/21/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/21/2025 07:16 PM - It Cannot Be Edited


Created By: Valeria Conway On 11/21/2025 at 03:19 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: HERITAGE HOME CARE LLC
FACILITY NUMBER: 565850355

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/21/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above by not conducting emergency drills quarterly as required by regulations which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/05/2025
Plan of Correction
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Administrator and back up administrator agreed to conduct an emergency drill before POC due date and to continue conducting emergency drills every 3 months after thereafter to ensure compliance with regulatory requirements. Also, Administrator and back up administrator agreed to submit a written statement of understanding outined in regulation 1569.695.
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: 11/21/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/21/2025


LIC809 (FAS) - (06/04)
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