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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850406
Report Date: 07/01/2025
Date Signed: 07/01/2025 01:58:44 PM

Document Has Been Signed on 07/01/2025 01:58 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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:SALLY RESIDENTIAL CARE HOME 3FACILITY NUMBER:
565850406
ADMINISTRATOR/
DIRECTOR:		AKINMADE, OLUWATOSINFACILITY TYPE:
740
ADDRESS:953 ANDANTE COURTTELEPHONE:
(818) 274-1809
CITY:CAMARILLOSTATE: CAZIP CODE:
93012
CAPACITY: 6CENSUS: 5DATE:
07/01/2025
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Sara JacksonTIME VISIT/
INSPECTION COMPLETED:
02:15 PM
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Licensing Program Analyst (LPA) Martha Arroyo arrived at the facility unannounced to conduct a post-licensing visit today. Upon arrival, the LPA met with facility staff who contacted Administrator, Sara Jackson and at this time the reason for the visit was explained. The Administrator arrived at the facility at approximately 09:50 AM.

Beginning at 09:55 AM, the LPA along with Administrator toured the physical plant areas inside and outside to ensure there are no health and safety hazards and that facility is in compliance with Title 22 Regulations. The following was observed:

KITCHEN: The LPA observed the kitchen area to be clean. Kitchen appliances appeared to be in operable condition. The facility has a sufficient supply of two (2) days perishable and seven (7) days non-perishable food. The LPA observed knives and sharps in a locked drawer at the time of the visit. Refrigerator and pantry were checked for expirations dates; dates were clearly marked.

COMMON AREAS: This includes the living room, hallway, and dining area. The LPA observed the living room to be clean and properly furnished at the time of the visit. The dining area was observed to be equipped with adequate seating for resident use. All furniture throughout the facility was observed to be clean and in good repair. The LPA observed a new fire extinguisher with a purchase date of 08/04/2024. All exits in the facility were observed to contain functioning auditory alarms. The LPA observed a working telephone on premises. No tripping hazards were observed inside or out.

Report Continued on LIC 809C...

NAME OF LICENSING PROGRAM MANAGER: Desaree Perera
NAME OF LICENSING PROGRAM ANALYST: Martha Arroyo
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/01/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/01/2025
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 4
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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: SALLY RESIDENTIAL CARE HOME 3
FACILITY NUMBER: 565850406
VISIT DATE: 07/01/2025
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Report Continued from LIC 809...

BEDROOMS: There are five (5) bedrooms in the facility for resident use; four (4) are designated for single occupancy, and one (1) is designated for shared / double occupancy. All resident rooms were observed to be furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting. Additional clean linens and towel were observed in a storage closet by the hallway. The LPA observed personal hygiene items locked and inaccessible to residents in care at the time of the visit. Staff room observed on premises.

BATHROOMS: There are two (2) bathrooms at the facility. One (1) is designated as a private resident bathroom, and one (1) is designated as a shared/common resident bathroom. All resident bathrooms were observed to be clean and were equipped with nonskid surfaces. Grab bars were observed near resident toilets and were properly secured. Beginning at 10:00 AM, the water temperature was measured in resident bathrooms, and they measured within the required range of 105 and 120 degrees Fahrenheit.

OUTDOOR SPACE: The LPA observed an adequate shaded seating area with appropriate outdoor furniture for resident use. The facility has one (1) self-latching gate for emergency use. All passageways were observed to be clear of any obstructions. No bodies of water noted at the time of the visit.

GARAGE: The garage is attached to the house. Washer and dryer were observed inside. Laundry detergents and cleaning supplies were observed inaccessible to residents at the time of the visit. The LPA observed an adequate amount of emergency food and water at the time of the visit.

RECORD REVIEW: Record review began at 10:20 AM. Five (5) resident files were reviewed for but not limited to; signed admissions agreement, medical assessment, negative tb test results, consent for treatment form, pre-appraisal, appraisal, needs & service plan, and personal rights. All records were complete.

Three (3) staff files were reviewed for but not limited to; personnel record, health screening with negative tb test result, fingerprint clearance, first aid / cpr certification, and annual staff training. All files were in order.

Administrator Certificate valid until 07/26/2025. Renewal has been started and training is in progress.

The LPA conducted interviews with one (1) staff and one (1) resident during today's visit and no concerns were noted.

Report Continued on LIC 809C...

NAME OF LICENSING PROGRAM MANAGER: Desaree Perera
NAME OF LICENSING PROGRAM ANALYST: Martha Arroyo
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/01/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2025
LIC809 (FAS) - (06/04)
Page: 3 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: SALLY RESIDENTIAL CARE HOME 3
FACILITY NUMBER: 565850406
VISIT DATE: 07/01/2025
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Report Continued from LIC 809C...

MEDICATION REVIEW: Medication review began at approximately 12:00 PM. Medications are centrally stored and kept locked in a file cabinet adjacent to the kitchen. Medications for two (2) residents were observed. Medications appear to be given as prescribed at the time of the visit.

EMERGENCY DISASTER PLANNING: During today’s visit, the LPA reviewed facility's emergency disaster plan. The facility’s emergency disaster plan is up to date and is adequate. Emergency disaster drills are conducted quarterly; the facility’s last emergency disaster drill was conducted on 04/14/2025. Next emergency disaster drill is scheduled for mid July.

Exit interview conducted. Report was reviewed and copy provided.

NAME OF LICENSING PROGRAM MANAGER: Desaree Perera
NAME OF LICENSING PROGRAM ANALYST: Martha Arroyo
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/01/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2025
LIC809 (FAS) - (06/04)
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